Citation Nr: 1312769 Decision Date: 04/17/13 Archive Date: 05/02/13 DOCKET NO. 05-27 312 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for a left hip disorder, to include as secondary to the service-connected bilateral knee disabilities. 2. Entitlement to service connection for a low back disorder, to include as secondary to the service-connected bilateral knee disabilities. 3. Entitlement to a total disability rating based upon individual employability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney at Law ATTORNEY FOR THE BOARD D. M. Casula, Counsel INTRODUCTION The Veteran had active service from December 1973 to August 1975. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of the Augusta, Maine Regional Office (RO) of the Department of Veterans Affairs (VA) dated in November 2004 and in August 2007. In March 2008, the Board remanded this matter to the RO, via the Appeals Management Center (AMC), in Washington, D.C., in order to have an SOC (statement of the case) issued pursuant to Manlincon v. West,12 Vet. App. 238 (1999). Because an SOC was issued in July 2008, there was substantial compliance with the Board's March 2008 remand. Stegall v. West, 11 Vet. App. 268 (1998). Subsequently, in August 2009, the Board again remanded this matter to the AMC for further development, to specifically include obtaining a VA examination and opinion regarding the etiology of the left hip disorder and the low back disorder. The Veteran underwent a VA examination, which included an opinion, in September 2009, thus, as more fully explained below, there was substantial compliance with the August 2009 remand. Stegall v. West, supra. In October 2011, the Board issued a decision denying the Veteran's claims. The Veteran subsequently submitted a notice of appeal to the United States Court of Appeals for Veterans Claims (Court) indicating his disagreement with the denial of his claims. The parties then filed a joint motion for remand. By Order dated in April 2012, the Court granted the joint motion for remand, vacated the October 2011 Board decision, and remanded the appeal for readjudication consistent with the joint motion. In light of the joint motion being granted, in November 2012, the Board obtained a Veterans Health Administration (VHA) opinion to specifically address the issue of whether the Veteran's low back disorder and/or left hip disorder were aggravated by the service-connected right and left knee disabilities. In January 2013, the requested VHA opinion was obtained and associated with the record. FINDINGS OF FACT 1. The evidence of record preponderates against a finding that the Veteran's left hip disorder is causally or etiologically related to his active service, or a finding that the left hip disorder is proximately due to or the result of his service-connected right or left knee disabilities, on either a causation or aggravation basis. 2. The evidence of record preponderates against a finding that the Veteran's low back disorder is causally or etiologically related to his active service, or a finding that the low back disorder is proximately due to or the result of his service-connected right or left knee disabilities, on either a causation or aggravation basis. 3. The Veteran's service-connected disabilities do not meet the percentage criteria for TDIU under 38 C.F.R. § 4.16(a). 4. The level of industrial impairment attributable solely to the Veteran's aforementioned service-connected disabilities does not warrant referral for extra-schedular consideration under 38 C.F.R. § 4.16(b). CONCLUSIONS OF LAW 1. A left hip disorder was not incurred in or aggravated by the Veteran's active service, and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303, 3.310 (2012). 2. A low back disorder was not incurred in or aggravated by the Veteran's active service, and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303, 3.310 (2012). 3. The criteria for the assignment of a TDIU rating are not met, and the preponderance of the evidence is against referring this matter for consideration of individual unemployability on an extra-schedular basis. 38 U.S.C.A. §, 5107 (West 2002); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.15, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating a claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1), as amended, 73 Fed. Reg. 23,353 (April 30, 2008). This notice must be provided prior to an initial decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental SOC (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that any error in VCAA notice should be presumed prejudicial, and that VA bears the burden of proving that such an error did not cause harm. Sanders v. Nicholson, 487 F.3d 881 ( Fed. Cir. 2007). However, the U.S. Supreme Court reversed that decision, finding it unlawful in light of 38 U.S.C.A. § 7261(b)(2). The Supreme Court held that - except for cases in which VA failed to meet the first requirement of 38 C.F.R. § 3.159(b) by not informing the claimant of the information and evidence necessary to substantiate the claim - the burden of proving harmful error rests with the party raising the issue, the Federal Circuit's presumption of prejudicial error imposed an unreasonable evidentiary burden upon VA and encouraged abuse of the judicial process, and determinations on the issue of harmless error should be made on a case-by-case basis. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). In this case, the VCAA duty to notify was satisfied by way of letters sent to the Veteran in July 2004 (for the TDIU claim) and November 2008 (for the service connection claims) that fully addressed the notice elements in this matter. These letters informed the Veteran of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. The Board also notes that in the November 2008 letter, the Veteran was advised of how disability ratings and effective dates are assigned. See Dingess v. Nicholson, supra. Moreover, he has not demonstrated any error in VCAA notice, and therefore the presumption of prejudicial error as to such notice does not arise in this case. See Sanders v. Nicholson, supra. Thus, the Board concludes that all required notice has been given to the Veteran. The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claims. VA has obtained all identified and available service and post-service treatment records for the Veteran. Further, he underwent a VA examination in September 2009 and a VHA opinion was obtained in January 2013. With regard to the September 2009 VA examination and opinion, as noted above, the Veteran's claims were remanded in August 2009 for further development. Pursuant to the remand, in September 2009, the Veteran underwent a VA orthopedic examination to assess the etiology of the claimed left hip and back disorders. Although the Board, in the August 2009 remand, requested opinions addressing service connection on a direct basis for both claims and such were not obtained, the Board finds that no prejudice to the Veteran. As will be discussed more thoroughly below, the Board has not found competent and credible evidence of an in-service event related to the claims for the left hip and back disorders. Indeed, the Veteran has not asserted that his claimed hip and back disorders are directly related to an injury or disease in service; rather, he has solely contended that his left hip and back disorders are secondary to his service-connected knee disabilities. Without evidence of an in-service event, service connection cannot be granted on a direct basis. Thus, as there is no in-service event upon which to base opinions for left hip and back disorders on a direct basis, the Veteran is not prejudiced and the Board may proceed with a decision on this matter. 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). With further regard to the September 2009 VA examination, the Board notes that in the joint motion for remand, the parties indicated that in the September 2009 VA examination, the examiner opined that the Veteran's lower back and left hip conditions were not related to his knee disability, based on a lack of "evidence in the literature that [a knee disability such as Appellant's] would cause degenerative disease in the hip or lumbar spine". The parties noted that the VA examiner's opinion speaks to the question of secondary service connection in that it addressed whether those conditions may be "proximately due to or the result of a service-connected disease or injury", however, also noted that the VA examiner's opinion did not address whether those conditions may have been aggravated by the Veteran's service-connected knee disability. The parties concluded that absent any discussion of whether such aggravation may be present here, the VA examiner's opinion lacked sufficient detail for the Board to make a fully informed decision on the Veteran's claim, and that the Board erred in relying on this examination in denying the Veteran's claims for service connection. Thus, the Board finds that the September 2009 VA examination is adequate only to the extent that it addresses causation -- whether the Veteran's left hip and/or back disorder were caused by the service-connected knee disabilities. The Board notes that the VA examination in September 2009 included a review of the claims folder, and a history obtained by the Veteran. Further, examination findings were reported, along with diagnoses and opinions, which were supported in the record. Thus, the Board concludes that the September 2009 VA examination is adequate to the extent that it addresses the claim of secondary service connection for a left hip disorder and a low back disorder, on a causation basis. Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). With regard to the claim for secondary service connection for a left hip disorder and a low back disorder, on an aggravation basis, the Board obtained a VHA medical opinion, in January 2013, specifically addressing this question. The Board finds that the January 2013 VHA opinion is adequate only to the extent that it addresses aggravation - whether the Veteran's left hip and/or back disorder were aggravated by his service-connected knee disabilities. In that regard, the VHA examination in January 2013 included a review of the claims folder, and an opinion that was supported by specific references to the record and a detailed rationale. The Board acknowledges that the Veteran's representative has contended, in a letter dated in February 2013, that the January 2013 VHA opinion is "inadequate and does not comply with the terms of the Joint Motion for Remand . . . because it completely fails to address the central question of aggravation". For reasons also set forth below, the Board does not agree with the representative's assessment of the January 2013 VHA opinion. A review of the January 2013 VHA opinion shows that after providing a detailed synopsis of the most relevant aspects of the Veteran's case, the VA orthopaedic surgeon provided a definitive opinion regarding aggravation, followed by specific points of rationale supporting the opinion. While the VHA examiner followed the rationale with a more blanket opinion regarding the relationship between the Veteran's left hip and low back and his service-connected knee disabilities, the Board does not find that this diminishes or obviates the VHA examiner's initial statement of opinion regarding aggravation. Thus, the Board concludes that the January 2013 VHA opinion is adequate to the extent that it addresses the claims of secondary service connection for left hip and low back disorders on an aggravation basis. Barr v. Nicholson, supra. Thus, it appears that all obtainable evidence identified by the Veteran relative to his claims has been obtained and associated with the claims folder, and that neither he nor his representative has identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. The Board concludes that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him 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, supra. The Board concludes that VA has satisfied its duty to assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claims under the VCAA. No useful purpose would be served in remanding this matter for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). [Continued on Next Page] II. Factual Background Service treatment records (STRs) are negative for reports or treatment of any left hip or low back symptomatology. The July 1975 separation examination shows that the clinical evaluation of the lower extremities and spine was generally normal. On the associated separation report of medical history, the Veteran denied having any bone, joint, or other deformity, and also denied experiencing recurrent back pain. VA treatment records show the first indication of a low back disorder in July 2004, at which time an x-ray examination revealed degenerative disc disease of the lumbar spine. In April 2006, the Veteran reported having pain in his left knee, which he reported went up to his back. He continued to report experiencing low back pain during VA medical assessments in August and September of 2006. VA treatment records document treatment for the Veteran's left hip symptomatology. In October 2007, he reported a new onset of left hip and buttock pain. An October 2007 x-ray examination of the left hip revealed significant degenerative disease. Included in the Veteran's VA medical records is a February 2008 primary care record showing that he was noted to have osteoarthritis of the hips and low back. He underwent a clinical examination, after which the diagnosis of osteoarthritis was continued. The Veteran's VA treating physician opined that his back and hip pain were likely secondary to an altered gait from knee pain. On a VA orthopedic examination in September 2009, the Veteran reported having discomfort in his lower back and left hip, which was aggravated by prolonged standing, walking, squatting, kneeling, and climbing. He was noted to have sustained injuries to his knees while on active duty and to have undergone a right knee meniscectomy in 1984 and a left knee surgery in 2006. Following clinical examinations, the diagnoses included early degenerative joint disease of the left hip and degenerative disc disease of the lumbar spine, with radiculopathy. Based on review of the claims folder, the examiner opined that it was less likely than not that the Veteran's left hip impairment and lumbar spine degenerative disease were due to his service-connected knee impairment. In providing this opinion, the examiner noted that the Veteran was suspected to have Osgood-Schlatter's disease of his knee while on active duty and that he later underwent a lateral meniscectomy in the right knee and arthroscopic surgery in the left knee. The examiner commented that the Veteran did not have significant, severe degenerative joint disease of the bilateral knees, despite having worked for several years as a laborer following his separation from active duty in 1975. The examiner acknowledged that the Veteran had internal derangement of the knee, which required meniscectomy and arthroscopy surgery, but highlighted that there was no evidence in the literature that the development of Osgood-Schlatter's disease and internal derangements of the knees, meniscal tear, would cause degenerative joint disease in the hip or lumbar spine. In numerous statements submitted in support of his claims, the Veteran reiterated his contentions that his left hip disorder and low back disorder were both related to his service-connected left and right knee disabilities. In an August 2008 statement, he stated that his primary care physician informed him that his knee problems could be at least as likely as not the cause of his back and hip problems. He also stated that his "spine" physician told him that his walk could cause back and hip problems. A January 2013 VHA opinion notes that the Veteran's claims folders and provided a medical opinion. The VHA examiner opined that it was less likely than not that the Veteran's left hip condition was aggravated by his bilateral knee disability, and that it was less likely than not that the Veteran's lumbar spine degenerative condition was aggravated by his bilateral knee disability. For rationale for both opinions, the VHA examiner indicated that there was no medical evidence that a knee condition will cause a degenerative condition of the Veteran's hip or his lumbar spine; that the knee condition could actually be protective of his hip and his lumbar spine as it could limit his activity and thus prevent or minimize his degenerative hip condition and his degenerative lumbar spine condition; that the Veteran left the service in 1975, nearly 37.5 years prior, and was over 62 years old, and that people at that age not uncommonly have degenerative conditions of the hip and spine. Further, the VHA examiner indicated that it appeared the Veteran had hypercholesterolemia, which was associated with degenerative musculoskeletal conditions; that it was apparent that the Veteran was a smoker, which was associated with degenerative conditions of the musculoskeletal system and arthritis specifically; and that the Veteran had documented obesity, which was associated with degenerative conditions of the hip and the lumbar spine. The VHA examiner opined that it was more likely than not that the Veteran's left hip condition and his lumbar spine condition were due to non-service-connected and non-pre-existing knee conditions such as the fact that he had likely less activity, was of an age when arthritis was not uncommonly present, had hyperlipidema, was a smoker, and was obese. The VHA examiner indicated that all opinions were given to a reasonable degree of medical and surgical certainty. III. Analysis 1. Laws and Regulations Service connection may be granted for disability which is the result of disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309(a). The Federal Circuit Court recently held that the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In that regard, the Board notes that arthritis is listed as a chronic disease under 38 C.F.R. § 3.309(a). Further, service connection for certain "chronic" diseases, such as arthritis, may be established based on a legal "presumption" by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). In order to prevail on the issue of service connection, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be established on a secondary basis for a disability that is 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. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, nature and etiologies of left hip and low back disabilities, falls outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, supra (lay persons not competent to diagnose cancer). Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. It is the Board's responsibility to evaluate the entire record on appeal. 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. 2. Discussion The Veteran essentially claims that service connection is warranted for his left hip disorder and his low back disorder. Specifically, he contends that his claimed hip and back conditions are related to his service-connected left knee and right knee disabilities. According to the Veteran, his service-connected bilateral knee conditions have caused changes in his gait and posture, resulting in his left hip and back conditions. As an initial matter, the Board notes that the Veteran was granted service connection for a left knee disability and a right knee disability by way of a January 1979 rating decision. Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence weighs against the Veteran's claims for service connection for a left hip disorder and a low back disorder. The Board recognizes that the medical evidence shows that the Veteran currently suffers from degenerative joint disease of the left hip and degenerative disc disease of the lumbar spine. However, the preponderance of the medical evidence, as discussed below, does not indicate that the Veteran's current disorders are related to his period of active service or to a service-connected disability. First, the Board finds that the preponderance of the evidence of record does not show that the Veteran's left hip and low back disorders warrant service connection on a direct basis. Initially, the Board notes that the Veteran has not asserted that his claimed hip and back disorders are directly related to an injury or disease in service. Likewise, as discussed above, the Veteran's STRs, are negative for reports or diagnoses of left hip and low back disorders. In this regard, the Board finds that the July 1975 separation report of medical examination, which was completed approximately one month prior to his separation, is highly probative as to the Veteran's condition at the time nearest his release from active duty, as it was generated with the specific purpose of ascertaining his then-physical condition. Rucker v. Brown, 10 Vet. App. 67, 73 (1993). The July 1975 report of medical examination is entirely negative for any left hip or low back symptomatology and weighs heavily against the claims. Further on the associated July 1975 separation report of medical history, the Veteran denied having any bone or joint deformity or having recurrent back pain. The weight of the STRs, including the July 1975 separation report of medical examination, is greater than subsequent private medical treatment records based on a history provided by the Veteran. Indeed, the medical evidence does not show diagnosed left hip and low back disorders until many years after the Veteran's separation from active duty service. The medical evidence first reveals a diagnosis of left hip degenerative disease in October 2007, over thirty years following separation, and lumbar spine degenerative disc disease in July 2004, nearly thirty years following the Veteran's separation from active duty. The Board notes that evidence of a prolonged period without medical complaint and the amount of time that elapsed since active duty service can be considered as evidence against a claim. Maxson v. Gober, 230 F.3d 1330, 1333 (2000). Accordingly, entitlement to service connection on a presumptive basis is not warranted. See 38 C.F.R. § 3.307, 3.309. Second, the Board finds that the preponderance of the evidence does not show that the Veteran's left hip and/or low back disorders are etiologically related to his service-connected bilateral knee disabilities. See 38 C.F.R. § 3.310; Allen v. Brown, supra. In this regard, the medical evidence includes both positive and negative opinions as to whether the claimed disorders are related to the Veteran's bilateral knee disabilities. While the conclusions of a physician are medical conclusions that the Board cannot ignore or disregard, see Willis v. Derwinski, 1 Vet. App. 66 (1991), the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). In reaching the above determination, the Board acknowledges that in February 2008, the Veteran's VA physician essentially opined that his left hip and low back disorders were secondary to an altered gait from knee pain. While this opinion is favorable, the Board finds that it does not provide a basis to support an award of service connection. Specifically, the VA physician did not provide any rationale or give any indication whatsoever has to how she reached her conclusion. Additionally, there is no indication as to whether the VA physician reviewed any medical records in formulating her opinion. The Court has emphasized that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). Given this, the Board finds that the February 2008 VA physician's opinion lacks probative value. In contrast, the Board finds highly probative two VA opinions that are also of record - (1) the September 2009 VA examiner's opinion, which addressed whether a current left hip or low back disorder was related to the service-connected knee disabilities; and (2) the January 2013 VHA opinion, which addressed whether a current left hip or low back disorder was aggravated by the service-connected knee disabilities. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 299-301 (2008) ("The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches.") quoting Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). In that regard, the Board notes that the VA examiner's opinion in September 2009 was based on objective examination of the Veteran and a review of the claims folder, and determined that the Veteran's left hip and low back disorders were not caused by his service-connected left and right knee disabilities. This opinion is considered highly probative as to this aspect of the secondary service connection claim as it is definitive, based upon a complete review of the Veteran's claims folder, and supported by detailed rationale. Accordingly, the September 2009 VA examiner's opinion is found to carry significant probative weight as to the causation aspect of the Veteran's the secondary service connection claims. Further, the Board finds that the January VHA opinion was based on a thorough review of the claims folder, and determined that the Veteran's left hip and low back disorders were not aggravated by his service-connected left and right knee disabilities. This opinion is considered highly probative as to this aspect of the secondary service connection claim as it is specific, definitive, based upon a complete review of the Veteran's claims folder, and supported by detailed rationale. Accordingly, the January 2013 VHA opinion is found to carry significant probative weight as to the aggravation aspect of the Veteran's the secondary service connection claims. The Board reiterates that the it has considered the February 2013 written argument proffered by the Veteran's attorney that the January 2013 VHA opinion is "inadequate and does not comply with the terms of the Joint Motion for Remand . . . because it completely fails to address the central question of aggravation". The Veteran's attorney asserts the VHA opinion ". . . incorrectly focused on whether his left hip and lumbar spine conditions were due to his service-connected knee conditions." (Emphasis in the original). The Board disagrees with this assessment. For each question, the VHA examiner specifically stated "[i]t is less likely than not that the . . . condition is aggravated by his bilateral knee disability." (Emphasis added). While in the thorough explanation that followed this statement, the examiner stated there is no medical evidence that a knee condition will "cause" the Veteran's left hip or lumbar spine disorders, the use of this description does not abrogate the central finding of the VHA examiner that there was no aggravation when the entire context of the rationale for the opinion is considered. Indeed, in view of the VHA examiner's supposition that the service connected bilateral knee disability could actually be "protective" of his hip and lumbar spine, the assertion that the January 2013 opinion somehow does not address the question of aggravation is without foundation. The United States Court of Appeals for the Federal Circuit has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). "[I]t is not error for the BVA to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reason or bases. It is the responsibility of the BVA, . . . to assess the credibility and weight to be given to evidence." Owens v. Brown, 7 Vet. App. 429, 433 (1995). As the September 2009 VA examiner's opinion and the January 2013 VHA opinion are both supported by a detailed rationale and review of the Veteran's claim folder, the Board gives these VA and VHA opinions greater weight, as compared to the February 2008 VA treating physician's opinion. Having reached this determination, the Board acknowledges the Veteran's statements that both his primary care and "spine" physicians have essentially opined that the claimed disorders are related to his knee problems and his altered gait. While the claims folder includes the February 2008 opinion from the Veteran's VA primary physician, there are no additional medical opinions of record favorable to the Veteran's claim. Thus, the Veteran's statements as to a favorable etiological opinion from his "spine" physician are not for consideration. The Board has considered the Veteran's assertions that his left hip and low back disorders are related to his service-connected bilateral knee disabilities. In this instance, the Board finds the Veteran's statements as to the onset of his left hip and low back symptomatology to be both competent and credible. A Veteran's lay statements may be competent to support a claim for service connection where the events or the presence of disability or symptoms of a disability are subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a), 3.159(a); see Jandreau v. Nicholson, supra; see also Kahana v. Shinseki, supra. However, where, as here, his left hip and low back disabilities have not been shown by objective medical evidence to have been caused or aggravated by service-connected disability, there is in essence no objective support within the record for his contentions in this regard. While some symptoms of a hip or back disorder, such as pain, may be reported by a layperson, the diagnosis and etiology of the disability requires medical training. The Veteran does not have the medical expertise to diagnose himself with any disorder, nor does he have the medical expertise to provide an opinion regarding its etiology. Thus, the Veteran's lay assertions as to the etiology of his left hip and low back disorders are not competent or sufficient in this instance. Jandreau v. Nicholson, supra. The Board concludes that in this case the objective medical evidence outweigh the opinions, though sincere, of the Veteran. In sum, based on the foregoing, the Board concludes that the preponderance of the evidence is against the claims for service connection for a left hip and low back disabilities. As explained above, there is no support in the record for a grant of service connection for either a left hip or the low back on a direct or secondary basis. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt rule is not applicable. See 38 U.S.C.A. § 5107(b) ; 38 C.F.R. § 3.102 ; Gilbert v. Derwinski, supra. IV. TDIU Claim All Veterans who are shown to be unable to secure and follow a substantially gainful occupation by reason of service-connected disability shall be rated totally disabled. Total disability will be considered to exist when there is presented any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the schedular rating is less than total, a total disability evaluation can be based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16. It is the established policy of VA that all Veterans who are individually unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. The record reflects that the Veteran is currently receiving the following disability evaluations: 10 percent for degenerative arthritis of the left knee; 10 percent for left knee instability; 10 percent for residuals of right knee surgery; 10 percent for right knee limitation of motion; 10 percent for internal hemorrhoids; and a noncompensable evaluation for a right hand scar. His combined disability rating is 40 percent. Thus, the requirement for a combined disability rating of 70 percent or higher has not been met. 38 C.F.R. § 4.16(a). As the service-connected disabilities in this case do not meet the requirements for TDIU based on a combined disability rating, the Board has also considered whether the Veteran may be entitled to TDIU under 38 C.F.R. § 4.16(b). This regulation provided that Veterans who are unable to secure gainful employment by reasons of service-connected disabilities, but fail to meet the criteria in 38 C.F.R. § 4.16(a), shall receive extraschedular consideration. However, the Board finds that the evidentiary record does not support a conclusion that there are any unusual or exceptional circumstances present in the Veteran's case as to have warranted its referral to the VA Director of the Compensation and Pension Service. See 38 C.F.R. § 4.16(b). In this regard, there has been no indication that VA's Rating Schedule for disabilities is insufficient or inadequate to assign ratings for the Veteran's service-connected disabilities. On a Veteran's Application for Increased Compensation Based on Unemployment (VA Form 21-8940) received in December 2005, the Veteran reported that he had been unemployed since September 2002. He reported that he previously worked as a mailroom helper from May 1993 to May 2002. According to the Veteran, he became too disabled to work due to his bilateral knee disabilities. The Veteran's VA treatment records show that he was referred for vocational rehabilitation in January 2004. A January 2004 vocational rehabilitation consult note shows that his primary diagnoses, in part, were unemployment, polysubstance abuse. The Veteran underwent a vocational assessment in February 2004, during which he reported that he previously worked full time as a mailroom assistant and that he last worked in 2002. The Veteran reported that he completed two years of college and that he was a college graduate. His was assigned to the Incentive Therapy (IT) program in the laundry. Subsequent records dated in February and March of 2004 reflect that he continued to participate in the IT program. The claims file reflects that the Veteran's service-connected disabilities were assessed during a December 2005 VA joints examination. He did not have any current complaints with respect to his right hand. With regards to his hemorrhoids, he denied having any current treatment for this disability, but reported experiencing occasional bleeding and recurrent burning, itching, and drainage. The Veteran reported experiencing recurrent left knee pain and episodes of his left knee "slipping out of its hinges." For the right knee disability, the Veteran stated that he had occasional, recurring right knee pain that was not debilitating. He reported that his bilateral knee pain was not debilitating and that he could function and perform his daily activities. The clinical examination revealed an unremarkable linear scar on the right palm, with no tenderness, swelling, or functional abnormalities. The examination of the knees was significant for increased prominence of the tibial tubercle, bilaterally, and bilateral limitation of motion; there was no pain, weakness, fatigability, decreased endurance or incoordination noted. The anal examination revealed two, very small, unremarkable external hemorrhoids. Following a clinical examination, the Veteran was diagnosed with an unremarkable right palmar scar; recurring anal symptoms with no significant hemorrhoidal disease noted on examination; recurring left knee pain; and occasional recurring right knee pain, status post right knee surgery. In December 2005, the RO received a Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) from the Veteran's former employer, P.J. The employer confirmed that the Veteran worked as a mailroom helper from May 1993 to May 2002, and that he was fired from this employment. The Veteran's VA treatment records document that he participated in the Compensated Work Therapy (CWT) program from January 2005 to May 2005. During a March 2005 vocational treatment consultation, the Veteran reported that he had secured work with his family; however, the type of work was unknown. He stated that he intended to leave the program and move out of state after he completed all of his dental treatment. In an April 2005 treatment record, the Veteran's vocational rehabilitation specialist noted the Veteran's intentions to register with the State Department of Labor. VA treatment records document the Veteran's treatment for his service-connected disabilities and nonservice-connected disorders. These records document his report of bilateral knee pain. A May 2006 treatment record includes his report of having been unemployed for approximately four years. He reported that his usual or last occupation was as a mailroom helper. In July 2006, he underwent a left knee arthroscopy. On a VA examination in September 2009, the Veteran reported that he previously worked various labor jobs but that he stopped working as a laborer in 2002 after he injured his left knee. In light of the foregoing, the Board concludes the preponderance of the evidence does not show that the Veteran's service-connected disabilities are of industrial impairment significant enough to warrant referral for extra-schedular consideration under 38 C.F.R. § 4.16(b). Although the Veteran has asserted that he cannot work because of his service-connected bilateral knee disabilities, the Board finds that the evidence of record does not persuade the Board that such assertion, in conjunction with the evidence of record, warrants further consideration of TDIU on a extra-schedular basis. In this regard, the Veteran reported during the December 2005 VA joints examination that his bilateral knee pain was not debilitating and that he could function and perform his daily activities. While the Veteran is noted to have had some physical limitations related to his service-connected bilateral knees, hemorrhoids, and right hand scar disabilities, he has not provided persuasive evidence or information to support his contention that he was unable to work in any capacity whatsoever as the result of his service-connected disabilities. Thus, the preponderance of the evidence does not warrant referral for extra-schedular consideration of TDIU. While the Veteran has claimed that he has been unable to work due to his service-connected disabilities since 2002, the evidence is contradictory in this point preponderance of the evidence does not show that he was unemployable due to his service-connected disabilities. Initially, the Board highlights the Veteran's former employer, P.J. reported in December 2005 that the Veteran was fired from his employment as mailroom helper in May 2002. There is no indication from the employer's report that he was terminated due to a service-connected disability. Moreover, the Board again highlights that at December 2005 VA joints examination that his bilateral knee pain was not debilitating and that he could function and perform his daily activities. The Board further notes that the record indicates that subsequent to this employment, he subsequently received VA vocational rehabilitation from January to March of 2004 and was enrolled in CWT from January 2005 to May 2005. Significantly, the fact that the Veteran was involved in vocational therapy and CWT indicates a determination that the Veteran was able to train for or obtain a suitable job. Although he only participated in these programs for a short time, this was not due to his service-connected disabilities; instead, the Veteran withdrew from the CWT program as he intended to relocate. The Board further highlights that the Veteran has provided inconsistent statements as to the date that he last worked. On his claim for TDIU benefits, he claimed he last worked in 2002 and that he was unable to work due to his bilateral knee disabilities. However, VA treatment records showed that the Veteran actually participated in vocational therapy and CWT in a labor position from January to March of 2004 and from January to May of 2005. The Board again notes the Veteran's March 2005 and April 2005 reports that he secured employment with his family and that he intended to register with the State Department of Labor. Thus, it is apparent that the Veteran has worked, in some capacity, since 2002 and that he himself believed he had the ability to work. This evidence of actual employment, consisting of the Veteran's own reported employment history he gave while seeking vocational therapy and medical care, shows that his testimony as to an inability to work since 2002 is simply not credible. See Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). It also weighs against entitlement to a TDIU, as the record shows that the Veteran was employed as recently as in 2005. Given this, the preponderance of the evidence does not warrant referral for extra-schedular consideration of TDIU. The Board acknowledges that the Veteran no doubtedly had some limitations due to his service-connected disabilities during the period currently on appeal. However, these factors have been contemplated by the disability ratings assigned for his left knee, right knee, hemorrhoids, and right hand scar disabilities. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). While his service-connected disabilities may cause some economic inadaptability, this is taken into account in the assigned disability ratings. In this case, there is no credible showing that the Veteran is precluded from obtaining employment by reason of service-connected disabilities. The Board has considered the Veteran's own statements that he was unable to work due to his disabilities, and the Board finds these statements competent to describe the Veteran's current symptomatology and his work experiences. However, there is no medical opinion of record to support the contention that the Veteran is unable to work due to his service-connected disabilities. To the extent that the Veteran contends that the evidence shows that he was unable to work solely due to his service-connected left knee and right knee disabilities, the Board concludes that the Veteran lacks the vocational expertise or medical knowledge to provide such an opinion. See Kahana v. Shinseki, supra. And, as was previously explained, the Board finds credibility is lacking with respect to the Veteran's current assertions that he is unemployable because of his service-connected disabilities. Essentially, the Veteran has not provided competent and credible evidence that shows that he was unable to obtain any type of employment whatsoever solely based on his service-connected disabilities or otherwise shows that referral for extra-schedular consideration of TDIU benefits under 38 C.F.R. § 4.16(b) is warranted in this case. ORDER Service connection for a left hip disorder is denied. Service connection for a low back disorder is denied. Entitlement to a TDIU rating is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs