Citation Nr: 1313405 Decision Date: 04/22/13 Archive Date: 05/03/13 DOCKET NO. 09-42 391 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for lumbar spine disability secondary to service-connected bilateral knee disabilities. 2. Entitlement to service connection for bilateral hip disability secondary to service-connected bilateral knee disabilities. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Bosely, Counsel INTRODUCTION The Veteran served on active duty from April 1975 to April 1978. This case originally came before the Board of Veterans' Appeals (Board) on appeal from a January 2009 decision of the Milwaukee, Wisconsin Department of Veterans Affairs (VA) Regional Office (RO). In July 2011, the Veteran testified at a Board hearing before the undersigned and a transcript of this hearing is associated with the claims file. This matter was previously before the Board in July 2012 at which time it was remanded to the Agency of Original Jurisdiction (AOJ) for further development. The case has now been returned to the Board for further appellate action. FINDING OF FACT The weight of the most credible and probative evidence of record demonstrates that the Veteran's back disorder, currently manifested by degenerative disc disease, and bilateral hip disorder, currently manifested by degenerative joint disease (resolved) and hip strain, are less likely than not to have been caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The Veteran's current lumbar spine disorder is not proximately due to, or aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 2. The Veteran current disorder of either hip is not proximately due to, or aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Proper notice from VA must inform the claimant of any information and medical or lay 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the 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. VCAA notice must be provided prior to an initial unfavorable 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). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, regarding the duty to notify, the Veteran was sent letters in June 2008 and August 2008 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing the low back and bilateral hip issues on appeal. The letters also explained what type of information and evidence was needed to establish a disability rating and effective date. In light of these letters, which were sent prior to the January 2009 rating decision on appeal, no further development is required with respect to the duty to notify. Next, as indicated, VA has a duty to assist a claimant in the development of a claim. This duty includes assisting in the procurement of service treatment records, all relevant pre-and post-service treatment records, and by providing an examination, when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. "Relevant records" in the context of VA's duty to assist "are those records that relate to the injury for which the claimant is seeking benefits and have a reasonable possibility of helping to substantiate the [] claim." Golz v. Shinseki, 590 F.3d 1317, 1321 (Fed. Cir. 2010) (quoting BLACK'S LAW DICTIONARY 1316 (8th ed. 2004), "defining 'relevant' as '[l]ogically connected and tending to prove or disprove a matter in issue; having appreciable probative value-that is, rationally tending to persuade people of the probability or possibility of some alleged fact.'")). Not all of a claimant's medical records will be relevant to a VA disability claim. Id. Specifically, the claims file contains the Veteran's service treatment records, as well as all available post-service medical records, both VA and private (non-VA) shown to be relevant to this appeal. In addition to the documentary evidence, the Veteran's testimonial statements are of record, including testimony provided at a hearing before the undersigned. Importantly, the undersigned explained the issues on appeal and attempted to identify any pertinent evidence that may have been overlooked; therefore, all hearing officer duties as presently directed by 38 C.F.R. § 3.103(c) have been satisfied. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010); see also Procopio v. Shinseki, 26 Vet. App. 76, 80 (2012) Overall, the Board has carefully reviewed the relevant records and statements accordingly, but finds that they identify no available evidence, such as additional medical records, relevant to this appeal that remains outstanding. In fact, at his Board hearing, the Veteran indicated that all available private records had already been received by VA. This is significant because the evidentiary record indicates that some private records, such as those associated with the Veteran's treatment for a post-service workplace injury, remain outstanding. However, the duty to assist does not extend to records that do not exit. See 38 C.F.R. § 3.159(c)(1) (2012). Moreover, the Veteran was provided a SSOC in January 2013. This SSOC listed the evidence used to decide the claim and provided the Veteran with an additional opportunity identify any additional evidence. The Veteran did not respond. Accordingly, the Board is satisfied that no additional records are available in this case for which even reasonable efforts could be undertaken to help the Veteran substantiate the claim. See 38 C.F.R. § 3.159(c). Also, the Veteran was afforded several VA examinations, most recently in August 2012, to address the medical questions raised by the case. The Board finds that the VA examinations, particularly the August 2012 examination, are adequate to decide the case because, as shown below, they were based upon consideration of the Veteran's pertinent medical history, including his lay assertions and his current complaints, and because they sufficiently inform the Board of the examiners' medical judgment on those medical questions and the examiners' essential rationale for their opinions. See Monzingo v. Shinseki, 26 Vet. App. 97, 105 -106 (2012); Barr v. Nicholson, 21 Vet. App. 303 (2007). In his October 2009 substantive appeal (VA Form 9), the Veteran questioned the adequacy of a January 2009 VA examination. Of note, he alleged that the VA examiner never physically examined him and the entire examination lasted only 20-30 minutes. Without regard to the merits of the Veteran's complaints, the Board observes that he was afforded a subsequent examination in August 2012. The Veteran has not questioned the adequacy of this latter examination. Furthermore, for the reasons explained below, the Board finds that this August 2012 VA examination is the most persuasive and probative evidence of record on the medical questions raised by the case. The Board accordingly finds no reason to remand for further examination. Correspondingly, the Board wishes to note at this point that three favorable etiology opinions from the Veteran's private (non-VA) medical providers are discussed below. These opinions are ultimately found to have reduced and limited probative value, in part because the opinions are unclear, tentative, and equivocal in nature. Under limited circumstances, the Board has an obligation to seek clarification if a private examination is unclear. See Savage v. Shinseki, 24 Vet. App. 259, 269-71 (2011). The present case does not involve such a situation. To the contrary, the missing information in these private examination reports here is a matter of opinion rather than factual and objective information. See id. Accordingly, remand for clarification of the private examiners opinions is not warranted. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the appeal. 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). As a final preliminary issue, the Board also finds that there was substantial compliance with the July 2012 Board remand directives. Specifically in this case, upon remand, (1) outstanding VA treatment records were obtained; (2) the Veteran was afforded an adequate VA examination; and (3) and then the matter was readjudicated in an SSOC, as directed by the Board. Accordingly, there was substantial compliance with the prior Board remand directives. Accordingly, no further remand is necessary. See Stegall v. West, 11 Vet. App. 268 (1998); see D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to the internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). II. Analysis The Veteran contends that service connection is warranted for disorders of the lumbar spine and bilateral hips. He maintains that these disorders are secondary to his service-connected knee disabilities. In fact, he made clear during his Board hearing that he was not alleging any other alternative theory of entitlement, such as in-service incurrence, chronicity during service, or continuity of symptomatology after service. See Hr'g Tr. 3, 9. Consequently, the Board's will address only his secondary theory of entitlement. See Moody v. Principi, 360 F.3d 1306, 1310 (Fed. Cir. 2004); DeLisio v. Shinseki, 25 Vet. App. 45, 53-54 (2011). Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection generally requires evidence establishing three elements: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999). Service connection may also be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury, and for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187-89 (1993). Service connection on a secondary basis may be established with (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). "Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability. In the absence of a proof of present disability there can be no claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement of a "current disability" is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal; service connection may be awarded even though the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). A Veteran bears the "'evidentiary burden' to establish all elements of a claim, including the nexus requirement." Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). The Board's duty is to first determine the probative value of all pertinent medical and lay evidence of record based on its credibility and competency, and then weigh the probative value of the evidence regarding all material elements of a claim. See 38 U.S.C.A. § 7104(d); Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). A "veteran is given the 'benefit of the doubt' 'regarding any issue material' to the veteran's claim 'when there is an approximate balance of positive and negative evidence.'" Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § 5107(b)). Thus, if there is conflicting medical evidence, the Board may not ignore or disregard any medical professional's opinion, but may assign greater probative to one medical opinion over by providing an adequate statement of reasons or bases for doing so. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Willis v. Derwinski, 1 Vet. App. 66, 70 (1991). A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In making all determinations, the Board must also fully weigh the probative value of the lay evidence of record against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). If credible, competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana, 24 Vet. App. at 438; Layno, 6 Vet. App. at 470 (a veteran is competent to report on that of which he or she has personal knowledge). Moreover, lay evidence must not be categorically dismissed as incompetent evidence of medical causation merely because it is lay evidence. See King, 700 F.3d at 1345. Rather, lay evidence may be competent and sufficient evidence of a diagnosis or nexus if (1) the particular condition at issue is the type of condition that is within the competence of a layperson, (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. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana, 24 Vet. App. at 433, n.4. The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person. See Jandreau, 492 F.3d 1367-77; see also Kahana, 24 Vet. App. at 438 (Lance, J., concurring); Robinson v. Shinseki, 312 Fed. Appx. 336, 339 (Fed. Cir. 2009) (nonprecedential). In the present case, the Board finds after careful consideration of all relevant evidence that the preponderance of the more probative evidence weighs against the claim. First, the Veteran is shown to be service-connected for (1) status post medial meniscectomy, right knee with history of internal derangement and instability; (2) degenerative arthritis, right knee, with painful motion; and (3) degenerative joint disease of the left knee associated with degenerative arthritis, right knee, with painful motion. Accordingly, there is evidence of a service-connected disability. See Wallin, 11 Vet. App. at 512. Second, the VA treatment records show that the Veteran is currently diagnosed with lumbar spine and bilateral hip disorders, particularly, degenerative disc disease (DDD) and spondylosis (with secondary left sciatica), and bilateral hip degenerative joint disease (DJD) (resolved) and hip strain, as confirmed most recently by a VA examiner in August 2012. Accordingly, the record demonstrates evidence of a current disability. See id. The evidentiary record, beginning with an October 1992 VA examination (for the right knee), demonstrates that the Veteran has an antalgic gait. Furthermore, he underwent right knee arthroscopy and debridement at VA in May 1996. Private (non-VA) treatment records first document complaints of back pain in July and August 1996. Complaints of hip pain first appear in private records from October 1999, when the Veteran reported left hip pain for two- to-three years, which he reported first occurred during intercourse with a friend. Also relevant, the record establishes a functional leg length discrepancy (LLD) resulting from varus deformity of the right knee. The central question before the Board concerns whether the record contains medical nexus evidence establishing a connection between the current disability and the service-connected disability. See id. On this question, there is some evidence supporting the claims and some evidence weighing against the claims. (Although the evidentiary record contains substantial medical records showing ongoing treatment for his back and hip complaints, the Board will take notice of, but not discuss, these records as they are not pertinent to the central question of causation and aggravation.) Weighing against the claims, a private October 1999 private neurology consultation, as noted above, documents the Veteran's complaints of left hip pain for 2-3 years, which occurred during intercourse with a friend. Similarly, a private evaluation in March 2003 notes that the Veteran has been complaining of low back pain and left lower extremity pain since August 1996, when he was hurt at work (he twisted and felt a pop in his low back area) with pain since then. The Board observes that these treatment records directly contradict the Veteran's July 2011 Board hearing testimony declaring that he did not have any injuries to the back or hips after service. Hr'g Tr. 4. Otherwise, these treatment records have little probative value weighing against the claims because they concern only the question of causation. In other words, even if these records show that back pain and left hip pain began with a discrete injury, such a finding does not exclude the possibility that a back and/or left hip disorder has subsequently been aggravated by the service-connected knee disabilities. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013). Also weighing against the claim, the Veteran underwent a VA joint examination in connection with the instant appeal in November 2008. After a review of the relevant history and X-rays, and a clinical evaluation, the examiner diagnosed bilateral hip mild DJD and lumbar spine DDD. The examiner opined that these disabilities are unrelated to the service-connected knee conditions as the medical literature does not support the contention that DJD of the knees causes or aggravates lumbar spine DDD or minimal hip DJD. The Board finds that this assessment is somewhat probative evidence weighing against the appeal as the VA examiner considered the relevant background and provided a supporting rationale. The probative weight assigned to this examination, however, is diminished because the VA examiner's opinion is not clear. Particularly, where the examiner found that the Veteran's back and hip conditions are "unrelated to" the knee disabilities, it is uncertain if the examiner intended the phrase "unrelated to" to encompass both questions of causation and aggravation. Thus, the Board assigns significant, but slightly reduced, probative value to the November 2008 VA examiner's opinion. See Nieves-Rodriguez, 22 Vet. App. at 304. In July 2010, the Veteran underwent a second VA examination. The Board finds that this VA examination is thoroughly persuasive. Specifically, the VA examiner, after reviewing the relevant history and X-rays and conducting a clinical examination, diagnosed the Veteran with bilateral hip DJD and lumbar spine degenerative change. With regard to etiology, the VA examiner opined that these disabilities were age-related and not caused by or aggravated by the service-connected knee condition. He explained that he had not seen any studies that support the contention that disability to the hips and spine could be caused by stress and overuse of these areas because of extremities being favored during walking and other activities. He noted that a study by Merchant and Dietz in the Journal of Bone and Joint Surgery in 1989 looked at the long term outcome of an angular deformity of a weight bearing bone and found no increased incidence of knee pain or radiographic changes, even in patients with large angular deformities in the weight bearing leg. In addition, the examiner noted that the preponderance of data regarding overuse of a joint such as that in moderate runners showed no increased risk of arthritis and in fact that this may have a protective effect to the joint. Lastly, the examiner noted that the Veteran's gait was only mildly antalgic and would not be sufficient to affect other joints. Again, the Board finds that the July 2010 VA examiner's opinion is significant. Not only is it based on an understanding of the facts of the case, but it is clear and supported by a sound explanation. The Board finds particularly persuasive that the VA examiner justified the opinion by discussing alternative risk factors/etiologies and cited a supporting medical study, which indicates that the VA examiner researched the question and did not rely on his own clinical experience alone in reaching his conclusions. See, e.g., Guinn v. AstraZeneca Pharmaceuticals LP, 602 F.3d 1245 (11th Cir. 2010) (finding that a medical expert's testimony as to causation was unreliable because her opinion amounted to ipse dixit ("he himself said it")). Thus the VA examiner's opinion is afforded greater probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Finally, the Veteran was afforded a third VA examination in August 2012 (pursuant to a Disability Benefits Questionnaire (DBQ) examination). The Board also finds that this VA examination is cogent. First, the VA examiner thoroughly reviewed the background of the case. Specifically, the VA examiner noted, with regard to the history of the case, that the Veteran gave a history of low back problems progressive in nature since the mid-1990s, and that he felt his complaints were aggravated by his knee disabilities. The pain occasionally radiated into the left thigh and leg with associated numbness at times. He had to use a cane for almost all ambulation. He had to use it for assistance due to both his knee and low back. The Veteran complained of bilateral hip pain, left worse than right, dating back to the mid-1990s. He denied any trauma. The VA examiner also reviewed diagnostic testing, including X-rays of the spine demonstrating mild/moderate multilevel degenerative disc disease and spondylosis, and secondary left sciatica caused by DDD, but with no spondylolisthesis or scoliosis noted. X-rays of the bilateral hips showed normal bony anatomy of the hip and pelvis with no joint space narrowing, sclerosis or osteophyte formation that would suggest DJD. The Board finds that this is an accurate factual history. With regard to etiology, the VA examiner then gave a conclusive opinion and explanation. In particular, the August 2012 VA examiner opined that degenerative conditions in the lumbar spine and bilateral hips were less likely than not caused by the knee disability. The VA examiner explained that such findings are most commonly an age and over use phenomenon. The VA examiner explained that physical examination shows the Veteran to have an antalgic gait and a varus deformity of the right knee with a 1-2 cm LLD. However, in the orthopedic realm, patients were commonly seen with more severe deformities in the lower extremities that have no associated conditions in the lumbar spine. The examiner reported that there have been studies performed that look at this specific situation, and a previous examiner cited one study. These studies show there is not a significant correlation between angular deformity of the lower extremity and degenerative conditions in other joints. It was also the VA examiner's opinion that the current lumbar spine DDD and bilateral hip disorders were less likely than not aggravated by the service-connected knee disability. The VA examiner reiterated the above opinion, again pointing out that he did not feel the Veteran's antalgic gait is severe enough to exacerbate the lumbar or bilateral hip condition. Although the Veteran's varus deformity of the knee does result in a minor LLD, it was the VA examiner's opinion that the varus deformity and the resultant LLD does not aggravated his lumbar spine disorder. After careful consideration, the Board finds that the August 2012 VA examiner's opinion is highly persuasive. As with the July 2010 VA examiner, the August 2012 VA examiner accurately and comprehensively reviewed the pertinent evidence of record. Additionally, he articulated clear opinions addressing both causation and aggravation theories. The VA examiner also justified his opinion with a careful explanation detailing his reasoning. Notably, the VA examiner addressed both general and specific causation. That is, he discussed the medical reasons explaining not only whether a knee abnormality, such as the Veteran's, could possibly cause a current back or hip disorder, but he also answered whether this Veteran's knee condition actually resulted in or aggravated a back and hip disorder. Such thoroughness heightens the probative value of the opinion. See, e.g., Guinn, 602 F.3d at 1249 n.1 (explaining the distinction between specific and general causation, and stating that "[s]pecific causation refers to the issue of whether the plaintiff has demonstrated that the substance actually caused injury in her particular case"). For these reasons, the August 2012 VA examination is afforded significant probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. In summary, the evidence weighing against the appeal includes three VA examiners' opinions, two of which are highly persuasive evidence. Supporting the appeal, the Board again takes notice of the October 1999 private neurology evaluation for left hip pain, previously noted above. Of note here, the neurologist documented that the Veteran's "[t]he past medical history is not contributory other than for the above-mentioned injury of the knee and subsequent surgery to it." The Board notes that this statement, by inference, indicates that the neurologist found the Veteran's knee injury (i.e., his service-connected right knee condition) to have contributed to the left hip pain being evaluated. Such a statement would therefore be favorable to the claim. However, this statement is afforded limited probative value for two reasons. First, no explanation is given. Thus, it is unclear why or in what way the knee disability was found contributory. See Nieves-Rodriguez, 22 Vet. App. at 304 (a medical opinion without explanation is less probative); see also Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Second, on follow-up in October 1999 and November 1999 this same neurologist noted the opposite conclusion: that the past medical history is not contributory. This would indicate, by inference that, upon further investigation, the neurologist found the knee disability to be noncontributory to a left hip disorder. Again, however, without an explanation, the Board is only able to speculate as to the neurologist's intended meaning. See Kahana, 24 Vet. App. at 435 (the Board may permissibly draw 'inference[s] based on the evidence' as long as any inference resulting in a medical determination is independent and cited). Such lack of clarity again limits the probative weight assignable to this assessment. See Nieves-Rodriguez, 22 Vet. App. at 304. For these reasons, the Board assigns no weight to this evidence. See id. Next, the record includes a November 1999 private rheumatology record, which notes that the Veteran worked as a welder, and "the work probably aggravates his condition." (The Board observes that this statement, although tending to actually weigh against the claim, is not conclusive as it does not exclude the possibility that the service-connected knee disability also aggravates the Veteran's condition. See El-Amin, 26 Vet. App. 136.) Otherwise, the rheumatologist measured the Veteran's LLD, and then documented an assessment of low back pain, doubt SI joint disease. Most pertinent to the Veteran's appeal, the rheumatologist then observed: "I think primarily his problem is mechanical by length discrepancy of the lower extremities." This opinion supports the Veteran's low back claim as it appears to favorably relate a low back condition to the service-connected knee disabilities. However, the probative value of this opinion is limited as the rheumatologist opined only "I think," which leaves the Board with an impression that this assessment was tentative. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (holding that medical evidence that is speculative, general, or inconclusive cannot be used to support a claim). Moreover, the rheumatologist did not explain the reasoning for his conclusion, which limits the probative value assignable. See Nieves-Rodriguez, 22 Vet. App. at 304. Consequently, the rheumatologist's opinion is not persuasive evidence supporting the appeal. Next, the VA outpatient treatment records show that the Veteran underwent physical therapy for his joint pain. Most pertinent here, several physical therapy records, such as in December 2009 and June 2012, reflect the physical therapist's opinion that the right knee disability impacts the hips and back. For instance, in December 2009, the physical therapist wrote that the Veteran's severe DJD of right knee and deformity is "causing extra load and strain on his right hip and back. His gait is altered due to functional short right leg and also pain." Similarly in June 2012 a physical therapist: "Suggested consideration of knee replacement. Due to severe deformity and instability of right knee his gait is altered and he is placing significant load on right hip tissue as well as strain on lumbar region. Even though he is young these issues will not resolve until knee is replaced." The Board finds that this VA physical therapist's opinion supports the Veteran's appeal. However, the opinion of this physical therapist is less persuasive than that of the August 2012 VA examiner's opinion (discussed above). Importantly, whereas the VA examiner is a medical doctor specializing in orthopedic issues a physical therapist is not. See generally STEDMAN'S MEDICAL DICTIONARY (27th Edition) (defining a physical therapist as an "allied health professional," which is "[a]n individual trained to perform services in the care of patients other than a physician or registered nurse"). This is evident in the thoroughness of the August 2012 VA examiner's opinion when compared with the physical therapist's unsupported and conclusory opinion. See Nieves-Rodriguez, 22 Vet. App. at 304. In other words, the physical therapist has medical training, but is not shown to have additional special training in assessing causal relationships, unlike the August 2012 VA examiner. See, e.g., VHA Directive 2008-005 (establishing the certification process for clinicians performing compensation and pension examinations); C&P Service Clinician's Guide. Thus, the probative value of the VA physical therapist's opinion is outweighed by that of the August 2012 VA examiner. Next, the evidentiary record includes a private March 2010 orthopedic consultation. After noting X-ray results (showing degenerative wear about the lower lumbar region; bilateral hip joints appeared to be maintained, no evidence of arthritis), the assessment was bilateral hip discomfort, probably secondary to degenerative wear about the lower spine. The Board observes that this opinion appears, on an initial reading, to be favorable to the Veteran's hip claim. However, upon closer scrutiny, it actually weighs against the appeal. Specifically, it indicates that the Veteran has a pain ("discomfort"), but no underlying disorder in either hip; as noted above, service connection may not be granted unless there is a currently diagnosed disorder. See Brammer, 3 Vet. App. at 225. Second, this opinion favorably relates the bilateral hip condition to the back, but not to either knee. Presumably, if the physician had found such a relationship to the knee, he would have stated it. A review of this private treatment record reflects that the physician was aware of the Veteran's knee problems because such was noted as the reason for this visit. Physical examination covered both the lumbar spine and knees. Additionally, the physician's other assessment was "Arthritis, bilateral knees, right worse than left." Because he did not, an inference arises that he did not find the bilateral hip condition to be related to either knee. See Buczynski v. Shinseki, 24 Vet. App. 221, 225-26 (2011) (noting that the Board could not rely on silence in medical records to conclude that the appellant's injury was not "exceptionally repugnant" because there was no medical reason for the examiner to address that subjective conclusion); see also Kahana, 24 Vet. App. at 440 (2011) (Lance, J., concurring). Finally, the physician's opinion is tentative, conjectural, and not supported with any rationale. For these reasons, the March 2010 orthopedic consultation is of little persuasive value. See Obert, 5 Vet. App. at 33; Nieves-Rodriguez, 22 Vet. App. at 304. Finally, the evidence supporting the appeal includes the Veteran's own lay testimonial statements, including his Board hearing testimony. Significantly, he relates his hip and back conditions to the service-connected knee disabilities, particularly the right knee. See Hr'g Tr. 3, 6. The Board initially observes that the evidentiary record calls into question the reliability of the Veteran's assertions. For instance, he testified at the Board hearing that he had no injuries after service to the back or hip. Hr'g Tr. 4. Yet, an October 1999 private neurology record (cited above) and a March 2003 private evaluation both expressly document his report of suffering two distinct post-service injuries. Accordingly, the Board finds that the Veteran's own testimonial assertions are of questionable veracity. The Board assigns them correspondingly limited probative weight. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). Moreover, although lay persons are competent to provide opinions on some medical issues, the specific issue in this case, concerning secondary causation and aggravation, falls outside the realm of common knowledge of a lay person. In other words, the central question in this case, whether a service-connected knee disability has caused or aggravated a hip or back condition, is a complex medical question, which is the subject of advanced medical knowledge concerning complex biological processes, anatomical relationships, and physiological functioning within the human body. Thus, it is not a question within the competence of a lay person. Because the Veteran's own opinion as to etiology is not competent evidence on this question, the probative value of his opinion is substantially outweighed by the highly probative, unfavorable evidence discussed above. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana, 24 Vet. App. at 435 (discussing competency). In summary, the favorable evidence of record consists of the several medical opinions, plus the Veteran's own lay assertions. However, such evidence, for the reasons given, is assigned minimal probative value. Overall, with careful consideration of the relative probative value of the unfavorable evidence, which is considerable, with that of the favorable evidence, which is minimal, the Board finds that the preponderance of the most probative evidence of record weighs against the claims of service connection. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claims are denied. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.310. ORDER Entitlement to service connection for a lumbar spine disability is denied. Entitlement to service connection for a bilateral hip disability is denied. ____________________________________________ Paul Sorisio Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs