Citation Nr: 1313429 Decision Date: 04/22/13 Archive Date: 05/03/13 DOCKET NO. 09-22 533 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for a left knee disability. 2. Entitlement to service connection for a left knee disability, to include as secondary to service-connected bilateral pes planus. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Elizabeth Jalley, Counsel INTRODUCTION The Veteran served on active duty from March 1987 to May 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Board notes that the Veteran's claim of entitlement to service connection for a left knee disability was originally denied in a September 1995 rating decision that was not appealed. This decision thus became final, and new and material evidence is required to reopen the claim before it may be adjudicated on its merits. In recharacterizing this claim, the Board recognizes that the theory of entitlement to service connection on a secondary basis, irrespective of whether it was considered expressly by the RO at the time of the initial denial of service connection, does not raise a new claim. See Roebuck v. Nicholson, 20 Vet. App. 307, 313 (2006) (holding that "although there may be multiple theories or means of establishing entitlement to a benefit for a disability, if the theories all pertain to the same benefit or the same disability, they constitute the same claim."). In other words, a separate theory of entitlement (as opposed to a separate diagnosis) is not a new claim, and must be addressed as part of the current claim. See Bingham v. Principi, 18 Vet. App. 470 (2004) aff'd sub nom. Bingham v. Nicholson, 421 F.3d 1346 (Fed. Cir. 2005); Ashford v. Brown, 10 Vet. App. 120 (1997). The Board has considered whether this recharacterization will prejudice the Veteran, who has not been notified of how to substantiate a new and material evidence claim. However, because the Board finds that new and material evidence has indeed been received, and this claim is reopened, it finds no prejudice to the Veteran in adjudicating this claim. In his June 2009 substantive appeal, the Veteran requested to be scheduled for a hearing before a Member of the Board at his local RO. He subsequently withdrew this request as reflected in a December 2010 report of contact. This statement has been accepted as a proper withdrawal of the hearing request pursuant to 38 C.F.R. § 20.704(e). Therefore, the Veteran's hearing request is deemed to have been withdrawn. In August 2011 and November 2012, the Board remanded this claim for additional development. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Entitlement to service connection for a left knee disability was denied by rating decision in September 1995. 2. When considered by itself or in connection with the evidence previously assembled, the evidence received since the September 1995 rating decision was not previously submitted, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a left knee disability. 3. The Veteran did not exhibit a left knee disability in service, arthritis of the left knee was not demonstrated within one year of separation from service, and any such disability is not etiologically related to any injury or disease during the Veteran's active service. CONCLUSIONS OF LAW 1. Evidence added to the record since the September 1995 rating decision is new and material; thus, the claim of entitlement to service connection for a left knee disability is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. §§ 3.156, 20.1103 (2012). 2. A left knee disability was not incurred in or aggravated by active service, arthritis of the left knee was not incurred within a year of separation from service, and any such disability is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Public Law No. 106-475, 114 Stat. 2096 (2000), substantially amended the provisions of chapter 51 of title 38 of the United States Code, concerning the notice and assistance to be afforded to claimants in substantiating their claims. VCAA § 3(a), 114 Stat. 2096, 2096-97 (2000) (now codified as amended at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012)). In addition, VA published regulations, which were created for the purpose of implementing many of the provisions of VCAA. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (now codified, in pertinent part, at 38 C.F.R. § 3.159 (2012)). The notice requirements of the VCAA require VA to notify the veteran of any evidence that is necessary to substantiate a claim, as well as the evidence VA will attempt to obtain and which evidence the veteran is responsible for providing. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Such notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements, however, may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Dingess, supra; Pelegrini, supra. The Board believes that the evidence has been developed to the extent necessary to adjudicate the issue of whether new and material evidence has been received to reopen the Veteran's claim of entitlement to service connection for a left knee disability. As will be discussed in greater detail below, the Board finds that new and material evidence has been submitted, and that this claim should be reopened. Thus, the Board need not further discuss the notification and assistance requirements that are particular to new and material evidence claims. With respect to the claim of entitlement to service connection for a left knee disability on the merits, the Board finds that the notification requirements of VCAA have been satisfied in this case. In this regard, the Board notes evidentiary development letters dated in March 2007 and November 2010 in which the RO advised the appellant of the evidence needed to substantiate his service connection claim, to include on a secondary basis. These letters advised the Veteran of his and VA's responsibilities under VCAA, to include what evidence should be provided by him and what evidence should be provided by VA. These letters, as well as a December 2008 letter, further advised the Veteran as to the type of evidence needed to substantiate both the disability rating and effective date elements of his claim, pursuant to the Court's holding in Dingess, supra. The Board notes that the December 2008 and November 2010 notice letters were not issued prior to the initial adjudication of the Veteran's claim in July 2007. The Veteran's claim, however, was readjudicated following the issuance of these notices, most recently in a February 2013 supplemental statement of the case. Thus, any deficiencies in the timeliness of these notice letters would not be prejudicial. The Board further finds that the duty to assist requirements of VCAA have also been satisfied in this case. 38 U.S.C.A. §§ 5103 and 5103A. Specifically, the Board finds that all obtainable evidence identified by the Veteran relative to the issue on appeal has been obtained and associated with the claims folder. In particular, the Board notes that the RO obtained the Veteran's service treatment records, VA medical records, medical records from the North Carolina Department of Corrections, and available private medical records. No additional, outstanding evidence has been identified by the Veteran as relevant to his appeal. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in initial service connection claims, the VA must provide a VA medical examination where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service; but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. The Veteran underwent VA examinations in connection with his left knee disability claim in May 2007, October 2011, and December 2012. VA also obtained an addendum to the October 2011 examination report in November 2011. The Board finds that, when taken together, the October 2011 and December 2012 VA examination reports are adequate for the purpose of determining the claim decided herein. Those examination reports indicate review of the claims file. During the examinations, the examiners elicited from the Veteran his history of complaints and symptoms. They provided clinical findings detailing the examination results and clinical diagnoses. The examiners also provided diagnoses and etiology opinions. These two reports provide etiology opinions and explain the reasons and bases for these opinions. For these reasons, the Board concludes that the VA examination reports in this case provide an adequate basis for a decision on the Veteran's claim. The evidence of record provides sufficient information to adequately evaluate the claim. Therefore, no further assistance to the Veteran with the development of evidence is required, nor is there notice delay or deficiency resulting in any prejudice to the Veteran. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). II. New and Material Evidence The Veteran is seeking entitlement to service connection for a left knee disability. He essentially contends that this disability developed secondary to his service-connected bilateral pes planus. Rating actions from which an appeal is not perfected become final. 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. The governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing and, after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200 (2012). A final decision cannot be reopened unless new and material evidence is presented. Pursuant to 38 U.S.C.A. § 5108, the Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with respect to that claim. Knightly v. Brown, 6 Vet. App. 200 (1994). For claims filed on and after August 29, 2001, new evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2012). Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that determined that no new and material evidence had been presented), will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). The Veteran need not present evidence as to each element that was a specified basis for the last disallowance, but merely new and material evidence as to at least one of the bases of the prior disallowance. See Shade v. Shinseki, 24 Vet. App. 110 (2010) (holding that it would be illogical to require that a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element). For the purpose of establishing whether new and material evidence has been submitted, the evidence is presumed credible unless it is inherently false or untrue, or it is beyond the competence of the person making the assertion. Justus v. Principi, 3 Vet. App. 510, 513 (1992). In the case at hand, the Veteran's service connection claim was denied in September 1995 based on the absence of left knee symptoms in service and the absence of evidence of nexus between any current left knee symptomatology and service. The Board further notes that, at the time of the rating decision, the record reflected that the Veteran complained of left knee numbness and pain, but no disability had been diagnosed. X-rays conducted in connection with a September 1995 VA examination reveal no significant left knee pathology. The examination report itself does not diagnose a current left knee disability. Of record at the time of the September 1995 rating decision were the Veteran's service treatment records and VA and private medical evidence. Since the September 1995 rating decision, new and material evidence has been submitted in the form of medical records containing a current left knee diagnosis. Specifically, the December 2012 VA examination report diagnoses mild degenerative joint disease of the left knee. This evidence is new in that it was not of record at the time of the September 1995 denial. It is material in that it reflects the existence of a current left knee disability, which had not been demonstrated at the time of the original denial. In short, the Board finds that the December 2012 VA examination report constitutes new and material evidence in that it is neither cumulative nor redundant of previously submitted evidence, and it appears to raise a reasonable possibility of substantiating the Veteran's claim. Accordingly, the Board finds that new and material evidence has been submitted to reopen the claim of entitlement to service connection for a left knee disability. To this extent, the benefit sought on appeal is granted. III. Service Connection Turning to the service connection issue on its merits, the Veteran has claimed entitlement to service connection for a left knee disability as secondary to his service-connected bilateral pes planus. In general, applicable laws and regulations state that service connection may be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That a condition or injury occurred in service alone is not enough; there must be disability resulting from that condition or injury. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a veteran 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" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for chronic disabilities, such as arthritis, if such are shown to have been manifested to a compensable degree within one year after the Veteran was separated from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As an alternative to the nexus requirement, service connection for these chronic disabilities may be established through a showing of continuity of symptomatology since service. 38 C.F.R. § 3.303(b)(2012). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). A disability which is proximately due to, or results from, another disease or injury for which service connection has been granted shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2012). The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability and not due to the natural progress of the nonservice-connected disease. Allen v. Brown, 7 Vet. App. 439 (1995). In the case at hand, the Veteran's service treatment records reflect that his left knee was found to be clinically normal at the times of his January 1987 enlistment examination and his April 1991 separation examination. He denied any history of, or current, left knee problems on his January 1987 medical history report. Otherwise, the Veteran's service treatment records reflect that he never complained of, or sought treatment for, symptoms of a left knee disability during service. The earliest post-service indications of a possible left knee disability appear in a July 1994 private medical record noting that the Veteran was seeking treatment for knee pain. This record notes that the Veteran had been experiencing knee pain for approximately two weeks. He also reported that a tire had hit his left knee when he was working on a car one week earlier. No diagnosis is listed. As noted above, no left knee diagnosis was made, and x-rays were found to be normal, upon examination in September 1995. The earliest left knee diagnoses of record appear in the North Carolina Department of Corrections treatment records from 1998. Specifically, a July 1998 treatment report reflects that the Veteran complained of left knee pain and swelling for one week. Following examination, the Veteran was assessed as having chronic degenerative joint disease. An August 1998 record assesses the Veteran as having a left knee strain. Subsequent VA and private medical records reflect that the Veteran has sought treatment for various complaints associated with his left knee. In relevant part, a December 2004 record notes an impression of probable early posttraumatic arthritis of the left knee. It also notes that x-rays show medial compartment narrowing of the left knee, and the diagnostic impression indicates the possibility of meniscal pathology. A November 2005 record notes that the Veteran reported having had left knee and foot pain on and off for two years. Another November 2005 record notes that meniscal deterioration was shown on magnetic resonance imaging (MRI). A January 2006 VA medical record notes an impression of a degenerated meniscus medial knee and early medial compartment osteoarthritis. This impression was based in part on interview and examination of the Veteran, and in part on findings made on MRI. Thus far, the Board notes that the record does not indicate the presence of a diagnosed left knee disability in service or for more than seven years following the Veteran's separation therefrom. With respect to chronic disability, arthritis was not found within one year of separation. The record does not contain any competent medical or lay evidence linking a current left knee disability directly to service. (This particular assertion will be discussed in more detail below in connection with the secondary service connection theory of entitlement.) Therefore, direct service connection must be denied. The Board will next consider whether the Veteran may be granted service connection for a left knee disability as secondary to his service-connected bilateral pes planus. As described in the June 2009 substantive appeal, the Veteran essentially contends that, "[w]hen the arch of my feet [collapsed], and the entire sole of my feet comes into complete contact with the ground, it pulls on everything that is connected to my feet and bones, thus causing degenerative joint disease of the left knee." The record contains examination reports from May 2007, October 2011, and December 2012 that address the etiology question. The Board will describe each of these opinions, in turn, and assess their probative values before reaching a conclusion on whether there is a nexus between the Veteran's left knee disability and his service-connected pes planus. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, his knowledge and skill in analyzing the data, and his medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other 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, 448-9 (2000). A May 2007 VA examination report diagnoses degenerative joint disease of the left knee. This diagnosis is based on interview and physical examination of the Veteran, but not on review of the claims file. The examiner did not offer an etiology opinion, but rather stated that it would be mere speculation to estimate any causal relationship between the Veteran's flat feet and his left knee condition. The examiner did not provide a rationale for this opinion. In Jones v. Shinseki, 23 Vet. App. 382 (2010), the Court noted that an examiner's conclusion that an etiology opinion is not possible without resorting to speculation is a medical conclusion that must be 'based on sufficient facts or data,' and the opinion 'must support its conclusion with an analysis that the Board can consider and weigh' to be adequate. It must be clear that the examiner considered 'all procurable and assembled data.' Moreover, in such cases the examiner should clearly and precisely identify what facts cannot be determined or that the actual cause of the claimed disability cannot be selected from multiple potential causes. In the case at hand, it is not clear based on the record why the May 2007 VA examiner was not able to render an opinion without resort to speculation. More specifically, the examiner made no reference to unavailable evidence or information that, if found, would allow the examiner to render an opinion. Nor does the examiner mention any uncertainties in the current state of medical knowledge that prevent an etiology opinion from being offered. Thus, the examiner's assertion of an inability to draw a link between the Veteran's left knee disability and his bilateral pes planus is inadequate. The Board therefore assigns no probative weight to the May 2007 VA examination report for the purpose of determining etiology. The Veteran next underwent a left knee examination in October 2011, and an addendum to this examination was obtained in November 2011. This examination report reflects review of the claims file and contains the Veteran's detailed description of his left knee symptomatology. In relevant part, the Veteran reported having had a spontaneous onset of left knee pain in 2006. He sought VA treatment on multiple occasions and began noticing more difficulty seven or eight months prior to the examination. A detailed physical examination of the left knee was conducted, and x-rays were taken. The x-ray report reflects that the Veteran's left knee was normal, and the ultimate diagnosis was of a normal left knee. The examiner's discussion of his lack of diagnosis notes that the Veteran's history is rather vague, noting that the Veteran has provided inconsistent statements with respect to the source of his left knee pain. The examiner ultimately concluded that it is less likely than not that the Veteran's left knee condition was caused by, resulted from, or was permanently aggravated by his pes planus condition. In a November 2011 addendum, the examiner noted that his conclusions were based on review of the medical literature, which did not support the contention that pes planus is a recognized cause of knee pain. The Board finds the October 2011 opinion and November 2011 addendum to be highly probative to the extent that they contain a thorough description of the Veteran's pertinent medical history and findings on examination, to include x-ray results. As noted above, this opinion was based upon interview and physical examination of the Veteran, radiology testing, review of the claims file, and review of the pertinent medical literature. Specifically, the Board notes that, while the examiner did not diagnose a current disability, he did provide an etiology opinion with respect to the Veteran's "knee pain." Furthermore, the examiner supported this opinion with reference to an absence of evidence in medical literature of a relationship between pes planus and knee pain. For these reasons, the Board finds that the October 2011 examination report with the November 2011 addendum is highly probative to the question of nexus. The Veteran also underwent a VA examination in December 2012, apparently for the purpose of reconciling prior diagnoses of left knee arthritis with the lack of diagnosis in the October 2011 examination report. The examiner was also asked to comment on the conclusion reached in an October 2009 VA examination report "that the Veteran's right knee degenerative joint disease was caused by his pes planus." The December 2012 examiner noted review of the entire claims file and in-person examination and diagnostic testing of the Veteran. It was noted that the Veteran has, or has had in the past, a diagnosis of mild degenerative joint disease of the left knee. The Veteran reported that his left knee condition had its onset in 2003. He reported that he did not injure his knee in service and noted that, while he had had occasional left knee pain in 1992, he did not seek treatment until 2003. Degenerative or traumatic arthritis was found on x-ray. The examiner opined that the Veteran's degenerative joint disease of the left knee is less likely than not caused by any incident or event that occurred during his period of service, including as due to his service-connected bilateral pes planus condition. The examiner's opinion was based in part on the fact that the Veteran was not treated for a left knee condition in service. The examiner also noted that the earliest clinical diagnosis of degenerative joint disease of the left knee was made in 2007, which leaves a gap of at least 16 years between this diagnosis and the Veteran's 1991 separation from service. The examiner noted that the October 2011 x-ray report characterizes the left knee disability as "[m]inimal early degenerative changes." The examiner noted that "[d]egeneration in the knee joint is a natural age related progression of the disease in the joint over a period of time." The examiner further noted that there is no established medical causal relationship between the development of degenerative joint disease in the Veteran's left knee and his service-connected pes planus condition. Finally, the examiner disagreed with the conclusion reached by the October 2009 VA examiner that there is a relationship between the right knee condition and the pes planus. The Board finds this opinion to be highly probative to the question at hand. With respect to the question of diagnosis, the Board notes that the presence of a current diagnosis does not contradict the negative etiology opinion that was provided in the October 2011 examination report and November 2011 addendum. The Board further notes that the December 2012 examination report has given a negative etiology opinion, both with respect to the question of direct service connection and the issue of secondary service connection. The December 2012 VA examiner has provided a clear etiology opinion with respect to the negative secondary service connection opinion that is well-supported with reference to the pertinent medical literature. The Board notes that the October 2009 etiology opinion asserting a relationship between the right knee disability and pes planus does not constitute a positive etiology opinion with respect to any relationship between the left knee disability and pes planus. Furthermore, the Board observes that review of the October 2009 etiology opinion makes it clear that the factors that justified the positive right knee etiology opinion do not exist with respect to the left knee. Specifically, the October 2009 VA examiner diagnoses "bilateral pes planus, right greater than left, chronic, with painful right ankle," and it finds that "the records support that the right ankle condition is most likely caused by the service-connected pes planus, and the right knee osteoarthritis is a direct consequence of the ankle condition, and thus is present as a consequence of service-connected conditions." The examiner further noted that "the records support that the right knee arthritis condition was proximately caused by service-related injury of the right ankle, and aggravation of right knee and ankle conditions are a natural consequence of time and degenerative joint disease, but nevertheless are a consequence of service-related injury." This opinion makes it abundantly clear that the Veteran has a right ankle disability, but not a left ankle disability, that has played a crucial role in the development of his right knee disability. Thus, the rationale for the right knee etiology opinion does not apply to the left knee service connection claim. Given that the October 2009 opinion depends upon the presence of a right ankle injury to find an indirect relationship between the right knee injury and pes planus, the Board finds that the December 2012 VA examiner's opinion (that the medical literature does not support finding a nexus between the left knee injury and pes planus) is not contradicted by the evidence of record. The Board notes that the only contrary opinion of record comes from the Veteran himself, who believes there is a link between his current left knee disability and his service-connected bilateral pes planus. As noted above, the Veteran contends that the collapse of his arches caused the soles of his feet to come into contact with the ground, which pulled down on everything connected to his feet and bones, resulting in degenerative joint disease. The Board recognizes that there are instances in which lay testimony can provide probative evidence in medical matters. A layperson may be competent to offer testimony on certain medical matters, such as describing symptoms observable to the naked eye, or even diagnosing simple conditions such as a dislocated shoulder. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). In the case at hand, however, the Veteran, as a layperson, is not competent to assert a causal link between any current left knee disability and his pes planus, especially considering that multiple medical examiners have stated that no medical literature even supports a direct link between the two. In short, the Board finds that the competent medical opinions of record are uncontradicted in concluding that it is less likely than not that the Veteran's current left knee disability is related to his military service, to include as due to his service-connected pes planus. In summary, the Board finds that a preponderance of the evidence is against finding a link between a current left knee disability and the Veteran's military service, to include as related to his service-connected pes planus. The Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against this claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, entitlement to service connection for a left knee disability is not warranted. ORDER New and material evidence having been received, the claim of entitlement to service connection for a left knee disability is reopened. Entitlement to service connection for a left knee disability, to include as secondary to service-connected bilateral pes planus, is denied. ____________________________________________ JENNIFER HWA Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs