Citation Nr: 1315050 Decision Date: 05/07/13 Archive Date: 05/15/13 DOCKET NO. 07-24 189A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a cervical spine disorder. 2. Entitlement to service connection for a left knee disorder. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Purdum, Counsel INTRODUCTION The Veteran served on active duty from June 1985 to June 1987, with subsequent Army National Guard service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 RO decision which denied service connection for cervical spine, left knee, left shoulder, right hip, and lumbar spine disorders; as well as service connection for loss of the right testicle and flat feet. The Veteran, in August 2007, perfected his appeal as to all denied issues. In October 2009, the Veteran testified before the undersigned Veterans Law Judge, seated at the RO in St. Petersburg, Florida. A transcript of the hearing has been associated with the claims file. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) (2012) requires that the party who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the Veteran's Board hearing, the VLJ and the Veteran's representative asked specific questions directed at identifying the specific elements required for each claim. The VLJ specifically sought to identify any pertinent evidence not currently associated with the claims file in that she inquired as to whether all evidence cited by the Veteran had been submitted. Neither the Veteran nor his representatives have asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Further, a review of the record also reveals no assertion, by the Veteran or his representative, that VA or the undersigned failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any other prejudice in the conduct of the Board hearing. Accordingly, the Veteran is not shown to be prejudiced on this basis. In a February 2010, the Board denied service connection for lumbar spine, left shoulder, and right hip disorders, and remanded the remaining claims of entitlement to service connection for cervical spine and left knee disorders, loss of the right testicle, and flat feet. In February 2012, the Board denied service connection for loss of the right testicle and flat feet and remanded the remaining claims of entitlement to service connection for cervical spine and left knee disorders for additional development. The file has now been returned to the Board for further consideration. FINDINGS OF FACT 1. The most probative evidence of record indicates that the Veteran's cervical spine disorder, diagnosed to include arthritis, is not due to his period of active service and was not manifest to a compensable degree within one year after separation from active service. 2. The most probative evidence of record indicates that the Veteran's left knee disorder, diagnosed to include arthritis, is not due to his period of active service and was not manifest to a compensable degree within one year after separation from active service. CONCLUSIONS OF LAW 1. A cervical spine disorder was not incurred in or aggravated by active service, and may not be so presumed. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1133, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. A left knee disorder was not incurred in or aggravated by active service, and may not be so presumed. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1133, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duties 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) (2012). Proper VCAA notice 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The notice requirements were met in this case by letters sent to the Veteran in July 2005 and May 2006, prior to the initial unfavorable Agency of Original Jurisdiction (AOJ) decision. Those letters advised the Veteran of the information necessary to substantiate his claim, and of his and VA's respective obligations for obtaining specified different types of evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). The May 2006 letter also explained how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable AOJ decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). That was done in this case. The Veteran has not alleged that VA failed to comply with the notice requirements of the VCAA, and he was afforded a meaningful opportunity to participate effectively in the processing of his claim, and has in fact provided additional arguments at every stage. Id. The Board thus concludes that VA's duty to notify has been satisfied. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA treatment records have been associated with the claims file, as well as his relevant private treatment records. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. In this regard, in January 2007, the RO certified as to the unavailability of the Veteran's service treatment records reflecting his period of active service from June 1985 to June 1987. However, a number of service-generated treatment records from this time period are contained in the claims file and available for review by adjudicators. These records include the report of the general medical examination conducted prior to his entrance onto active duty, various reports of treatment for complaints in service, and medical test reports, as well. Overall, the available records would appear to be fairly complete. The only document which would normally be included in such a collection of service treatment records that appears to be missing is a report of a general medical examination conducted in conjunction with the Veteran's separation from active duty. In any event, the Board is satisfied that all reasonable efforts to obtain any outstanding service treatment records were undertaken and that no further efforts to comply with the statutory duty to assist are required. 38 C.F.R. § 3.159(c). The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran was initially afforded a VA examination in April 2005. He underwent additional VA examination in May 2010, and additional opinions were submitted in March 2012 and December 2012. The VA opinions, based on review of the claims file and supported by rationale, and including considering of pertinent clinical findings and the Veteran's lay statements, are adequate to decide the claims herein. The Board thus concludes that VA's duty to assist has been satisfied. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duties to inform and assist the Veteran at every stage of this case. Therefore, the Board may proceed to consider the merits of the claim. Additionally, the Board finds there has been substantial compliance with its February 2012 remand directives. The Court has recently held that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268 (1998)) violation when the examiner made the ultimate determination required by the Board's remand.) The record indicates that the Appeals Management Center (AMC) obtained updated VA treatment records and additional VA opinions and later issued a Supplemental Statement of the Case (SSOC) in December 2012. See Stegall, supra, (finding that a remand by the Board confers on the appellant the right to compliance with its remand orders). Therefore, the Board will proceed to review and decide the claim based on the evidence that is of record consistent with 38 C.F.R. § 3.655 (2012). Service Connection Service connection for VA compensation purposes will be granted for a disability resulting from disease or personal injury incurred in the line of duty or for aggravation of a preexisting injury in the active military, naval or air service. See 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Active military, naval, or air service includes any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred in line of duty. 38 U.S.C.A. § 101(24) (West 2002); 38 C.F.R. § 3.6(a) (2012). Active duty for training is, inter alia, full-time duty in the Armed Forces performed by Reserves for training purposes or by members of the National Guard of any state, or any period of inactive duty training during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebral vascular accident occurring during such training. See 38 U.S.C.A. § 101(22) (West 2002); 38 C.F.R. § 3.6(c) (2012). Inactive duty training means, inter alia, duty other than full-time duty prescribed for Reserves or the National Guard of any state. 38 U.S.C.A. § 101(23) (West 2002); 38 C.F.R. § 3.6(d) (2012). When a Veteran seeks service connection for a disability, due consideration shall be given to the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the Veteran served, the Veteran's military records, and all pertinent medical and lay evidence. See 38 U.S.C.A. § 1154(a) (West 2002); 38 C.F.R. § 3.303(a). The mere fact of an in-service injury is not enough; there must be evidence of a chronic disability resulting from that injury. In order to establish service connection for a claimed disorder, the following must be shown: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may 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. See 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis, will be rebuttably presumed if they are manifest to a compensable degree within one year following active service. 38 U.S.C.A. § 1133; 38 C.F.R. §§ 3.307, 3.309. Where there is a chronic disease shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. See 38 C.F.R. § 3.303(b). When a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. See 38 C.F.R. § 3.303(b). The use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if: (1) the layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d 1372, 1376-77. As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). The Veteran contends that his cervical spine and left knee disorders had their inception during his period of active service from June 1985 to June 1987. He does not assert he suffered any particular injury, but rather, the cumulative stresses and strains inherent in active service, to include physical fitness training and carrying heavy packs on his back, caused his current cervical spine and left knee disorders. As he does not claim disability resulting from an injury during active duty for training or inactive duty for training performed as part of his responsibilities in the Army National Guard, the legal analysis of his claims will necessarily focus upon the time period from June 1985 to June 1987, when he was in active service. The Veteran's service treatment records indicate the Veteran presented for enlistment examination in October 1984, without abnormalities of the cervical spine or left knee. In February 1987, the Veteran requested a blood pressure check and reported numbness in the legs while running. The record before the Board contains voluminous post-service treatment records, which will be addressed as pertinent. Dela Cruz v. Principi, 15 Vet. App. 143, 148-49 (2001) (a discussion of all evidence by the Board is not required when the Board has supported its decision with thorough reasons and bases regarding the relevant evidence.) After active service, during periodic military examination in April 1991, the Veteran reported occasional cramping in the legs with exertion and right knee torn cartilage at age five. Physical examination at that time was silent for any abnormality of the left knee or cervical spine. During periodic military examination in November 1995, the Veteran reported a history of resolved childhood knee problems. The Veteran underwent military examination in January 2005 for retention in the Army National Guard. At that time, he presented without abnormality of the cervical spine or left knee and reported left knee swelling, for ten years, without a specific injury. Private treatment records dated in November 1990 indicate that the Veteran complained of back and neck pain that began three weeks ago, with increased work load. In October 1998, during private treatment, the Veteran reported left knee pain for two or three months, without specific injury. Private treatment records dated in April 2001 indicate that the Veteran was diagnosed with early degeneration in the cervical spine; and in April 2002, the Veteran reported neck pain that began six months prior, related to changing sleeping positions. He reported that his pain resolved after physical therapy. During private treatment in March 2002, X-ray examination revealed cervical lordosis, and mild degenerative joint disease; and in January 2003, he was diagnosed with osteoarthritis of the cervical spine. During private treament in January 2003 and February 2004, he complained of neck pain for 10 years. He underwent private chiropractic care from July 2003 to June 2005, for neck pain. In a July 2003 private treatment record, the Veteran reported that his symptoms appeared in 1990. Private treatment records dated in May 2005 indicate that magnetic resonance imaging (MRI) revealed fraying, mild tearing, and chondromalacia of the left knee. During private treatment in May 2005, the Veteran reported a seven-year history of left knee pain, and additional records dated at that time indicate that he reported such for eight years. Private treatment records dated in May 2005 indicate that the Veteran complained of neck pain for four to five years. Private treatment records dated in April 2007 indicate that the Veteran was diagnosed with left knee meniscus tear and osteoarthritis. VA treatment records dated in August 2009 indicate that he presented with chronic neck pain, treated with over-the-counter medication, and knee pain. He reported that his neck pain was slowly progressive. In October 2007, he was referred to VA physical therapy for left knee pain. During VA treatment in July 2008, he complained of increased neck pain after bowling. Throughout 2009, 2010, and 2011, the Veteran sought general VA treatment for neck and left knee back complaints. Of record is a March 2012 private summary of knee surgery. VA treatment records dated from May 2012 to July 2012 indicate that the Veteran underwent left knee physical therapy. In an August 2007 statement, the Veteran asserted that his research demonstrated that although normal activities of everyday life do not cause osteoarthritis, certain types of activities, including heavy lifting, puts repeated stress on a joint and increases the risk of developing osteoarthritis. He asserted that such is a slow, progressive disease, the rate of which varies widely from person to person. He also noted that he has a leg length discrepancy, and that such puts one at increased odds for knee osteoarthritis. He noted his 1998 finding of nominal spurring of the tibia, patella, and femur, and his childhood right knee torn cartilage at age five. In August 2007, the Veteran submitted internet articles about osteoarthritis, the joints such can effect, the wear and tear causing such, and the treatments available. At the time of the October 2009 Board hearing, the Veteran reported that he entered the Washington state Army National Guard, after separation from active service in June 1987, from August 1987 to May 2005. He reported that he was hired as a civil service military technician in September 1991, and that such required him to maintain his membership in the National Guard. He left such position in June 2005. He reported that he had numbness in his lower extremities in 1987, during active service, and that no cervical spine X-ray studies were ordered. He asserted that he ran in formation as part of his physical training exercise and lifted heavy radios and equipment and carried such on his back, some weighing approximately 70 pounds. He reported that his symptoms were "just something that came on," and that he played football both prior to and during high school. He clarified that he did not recall any specific neck injury during active service. He reported that after active service, in 1989, he started to complain of neck pain, and was treated for cervical lordosis or degenerative joint disease of the cervical spine. He noted that his records demonstrate that such a diagnosis was made in 1990, but that his complaint started one year prior, and that he treated such with over-the-counter medication at that time. As to his left knee, the Veteran reported, during his Board hearing, that there was no specific injury during active service, only "fair wear and tear." He reported that he wore a brace and had to straighten his knee as a child. He clarified that he did not enter active service with any knee problems. In a June 2008 statement, the Veteran reported that, based on the evidence of record, it is medically reasonable to expect to have some intermittent symptoms of asymptomatic degenerative osteoarthritis aging. He reported that from the physical contact and trauma associated with playing little league and high school football, his Army physical fitness training, and physical requirements of his military occupation specialty, it is medically reasonable to have years of pain and intermittent and constant symptoms of degenerative osteoarthritis, starting in 1987 and 1989 to the present. He asserted that the frequency of treatment shows that the conditions were aggravated by active service. He cited his in-service February 1987 complaints of numbness in the legs while running and his private physical therapy notes dated in November 1990, showing neck pain for one year. On VA examination in April 2005, the Veteran reported that he had discomfort in the cervical spine for the past five or six years, without particular history of injury. He was diagnosed with early degenerative changes of the cervical spine with minimal if any functional impairment. He reported a problem with his left knee first arising in 1998, without particular history of injury. He reported that such was not a significant area of impact. He was not diagnosed with a left knee disorder. In December 2007, Dr. E. a private physician, submitted an opinion to the Department of Labor. He reported that the Veteran was in good health and had no symptoms in 1991, when he went to work for the Department of the Army as a federal service technician. He reported that the Veteran's work required him to also be a member of the Army National Guard, and that he had to carry heavy items, some weighing more than 40 pounds, and work in a standing position on concrete floors, with sitting, walking, bending, crouching, reaching, stooping, and twisting. He reported that the Veteran began to have neck pain in 1997, with popping; and began to have pain in the left knee in 1998. He was diagnosed with traumatic arthritis and tendonitis of the cervical spine, and traumatic chondromalacia, meniscus tear, and straining of the lateral collateral ligament of the left knee. He opined that such arose out of the Veteran's employment. He reasoned that at age 42, it was medically reasonable for the Veteran to have some asymptomatic degenerative osteoarthritis of the neck and left knee (due to aging), but that it is not medically reasonable to have years of pain requiring the frequency of treatment shown, with his degree of pain and limited motion. In May 2009, Dr. B., a private physician, offered opinions, in pertinent part, as to the Veteran's cervical spine and left knee disorders. He reported that the Veteran reported numbness in both legs while running during active service, and had severe cervical spine problems reported by Dr. E. He opined that the Veteran's current cervical spine disorder is due to his experiences and trauma during active service. He reasoned that the Veteran entered the service fit for duty; that he had numbness in the legs during active service which can be caused by a neck osteophyte or cord compression; that he has X-ray evidence of a large osteophyte and reversal of lordosis and a stiff neck; that he has MRI evidence of spondylosis (degenerations) and bilateral neural foraminal narrowing; that the time lag between his active service injury/illness and his development of signs and symptoms is consistent with known medical principles and the natural history of the disease; that it is known that such an injury precipitates or accelerates the onset of the degenerative process of the spine; and that his records do not support another more plausible etiology or other risk factors, in or out of service, to explain his problems other than his service-time experiences. He included a recitation of medical literature focused on degenerative changes of the spine, with the most common history of severe low back pain coming immediately after or within a few hours of an injury, and tearing of ligaments and subluxation with eventual symptoms of degenerative arthritis. He also reported that the Veteran had severe left knee problems, as reported by Dr. E. He reported that the Veteran entered service fit for duty; that he has a number of left knee diagnosis of record; that the time lag between his active service injury/illness and his development of signs and symptoms is consistent with known medical principles and the natural history of the disease; and that his records do not support another more plausible etiology for his current left knee disorder other than his service-time experiences. On VA examination in May 2010, the Veteran reported having problems with his left knee in 1998, and equated such with the two years of active service and subsequent National Guard service; however, he denied actual left knee injury during active service. He was diagnosed with left knee patellofemoral syndrome and loose body, left knee. The Veteran reported that he had numbness in the legs during active service, and denied any problems with his cervical spine during that time. He reported the onset of his cervical spine symptoms in 1989. He was diagnosed with cervical spondylosis and degenerative disc disease. Subsequent to review of the claims file and physical examination of the Veteran, the examiner opined that the Veteran's cervical spine and left knee disorders were less likely as not linked to his period of active service. He reasoned that the Veteran did not complain of neck or left knee pain during active service, and that such conditions developed years later. He reported that he had reviewed Dr. B.'s comprehensive review and disagreed with his medical opinions. He reasoned that the numbness in the legs during active service is not likely related in any way to the cervical spine disorder, as the Veteran was noted to have a large anterior osteophyte on the spinal cord that does not impinge upon the spinal cord. He concluded that as there is no evidence of spinal cord impingent, there is no association between the Veteran's in-service numbness in the legs and his current cervical spine disorder. The Board, in its February 2012 remand, noted that the VA examiner, in May 2010, disagreed with Dr. B.'s opinion and sought clarification regarding the time lag for the development of arthritis and the symptoms of arthritis. In March 2012, a VA examiner reviewed the claims file again, and provided a negative nexus opinion. She noted that there was no complaint of cervical spine pain during active service, and that in her more than 30 years of experience evaluating spine conditions, numbness of the lower extremities is not a symptom indicating cervical spine conditions. She explained that cervical spine conditions cause upper extremity symptoms and cervical spinal cord compression causes upper motor neuron signs in the legs, including spasticity, ataxia, and bowel and bladder incontinence; and such are not present in the current case. She also reported that cervical myelopathy depends on the levels of spinal cord involvement and the symptoms of such involvement include numbness of the hands, clumsiness of the hands, arm and hand weakness, leg stiffness (walking like a robot), loss of balance, and urinary urgency; and such are not present in the current case. She specifically addressed Dr. B.'s opinion as to the development of arthritis and reported that Dr. B. and the Veteran are claiming that the current cervical spine disorder is due to trauma sustained during active service which did not present until much later. She reported that the term "traumatic" in post-traumatic arthritis refers to actual fractures or dislocations of a bone or joint, and not stresses or strains; and such fractures or dislocations are not present in the current case. She noted that even if present, the usual time frame for arthritis to occur, based on medical literature and personal and professional experience, after trauma is two to five years, at most. She reported that beyond such, there is no way to rule out other factors, including aging, a very significant factor; and that there may be other unknown trauma or injury in occupational daily life in the interval, documented or undocumented. In December 2012, a VA examiner noted that he had reviewed the claims file, as well as the above-referenced March 2012 private treatment records and VA treatment records of record, and provided a negative etiological opinion as to the Veteran's left knee. He reported that the first evidence of left knee pain is dated in 1998, with a two to three month history, and that the Veteran's active service ended in 1987. He thus concluded that the evidence does not support that the pain in the Veteran's left knee would develop 11 years following active service, and that intercurrent injury is unknown. Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and whether or not and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). The Board included Dr. E.'s opinion for the sake of completeness, especially since Dr. B. cited to such in his opinion. However, it is significant that Dr. E. attributed the Veteran's current cervical spine and left knee disorders to the years he spent in civilian status with the Department of the Army from 1991 to 2005, and not to his two years of active service from 1985 to 1987. While Dr. E. did discuss the Veteran's age and unusual treatment pattern, degree of pain, and functional impairment, with the development of cervical spine and left knee disorders; he did not offer an opinion as to the issue before the Board; whether the Veteran's current cervical spine and left knee disorders are related to his active service. Thus, the Board need not consider Dr. E.'s opinion in its analysis of the most probative medical opinion of record. Here, the VA examiners and Dr. B. both based their opinions on review of the claims file and offered reasoned bases for their opinions. There is no evidence that the probative value of Dr. B.'s opinion should be lessened on the basis that he did not physically examine the Veteran. He had available record of the Veteran's pertinent medical history and lay statements. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). However, it is significant that part of the basis for Dr. B.'s opinion that the Veteran's cervical spine disorder is related to his active service is that he experienced numbness in both legs while running and that such can be caused by a neck osteophyte or cord compression. He noted X-ray evidence of a large osteophyte. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. McLendon, 20 Vet. App. 79. Further, as noted above, the VA examiner in May 2010 specifically reported that the Veteran's large anterior osteophyte did not impinge upon the spinal cord. The VA examiner in March 2012 recited the Veteran's findings as to the osteophyte found on X-ray examination and provided a detailed basis, described above in full, for her opinion that the Veteran did not have the clinical picture required for the conclusion that his cervical spine disorder included symptoms in the bilateral lower extremities. Considering the speculative language used by Dr. B., the specific clinical finding that the Veteran's osteophyte did not result in spinal cord impingement, and the more detailed rationale provided by the VA examiner, the March 2012 VA opinion is more probative as to this issue. Also, the Board finds it significant that while Dr. B. reasoned that the time lag between the Veteran's active service injury/illness and his development of signs and symptoms of arthritis related to the cervical spine and left knee is consistent with known medical principles and the natural history of the disease, Dr. B.'s included medical literature clearly described situations where severe low back pain immediately or within a few hours of an injury, and tearing of ligaments and subluxation occurred prior to the eventual symptoms of degenerative arthritis. Such is not the case in the present appeal. Conversely, the VA examiner specifically addressed Dr. B.'s opinion and specifically reported that the traumatic arthritis to which Dr. B. cited refers to actual fractures or dislocations of a bone or joint, and that such is not the case in the present appeal. While the VA examiner did not specifically include the left knee in her discussion of the medical literature as to the development of arthritis, it remains that Dr. B. offered the same statements as to arthritis of the cervical spine and the left knee, and the VA examiner, as requested by the Board, discussed Dr. B.'s opinion as to arthritis thoroughly. Considering that the medical literature cited by Dr. B. does not refer to a similar clinical picture to that of the Veteran and the detailed rationale provided by the VA examiner specifically considering the issue of the development of arthritis, the Board finds that the March 2012 VA opinion is more probative as to this issue. Further, the Board reads the remaining basis for Dr. B.'s negative etiological opinions, that the Veteran's records do not support another more plausible etiology for his current cervical spine and left knee disorders other than his service-time experiences, as tantamount to those opinions based on mere speculation. In essence, Dr. B. opines that the Veteran's cervical spine and left knee disorders are related to his active service because there is no other explanation. Ultimately, noncommittal opinions like this amount to "nonevidence," neither for nor against the claim, because service connection may not be based on speculation or remote possibility. See generally Bloom v. West, 12 Vet. App. 185 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). See also 38 C.F.R. § 3.102 (when considering application of the benefit-of-the-doubt doctrine, reasonable doubt is one within the range of probability, as distinguished from pure speculation or remote possibility). The VA opinions of record, supported by rationale and considering the Veteran's in-service physical fitness requirements and responsibilities carrying heavy loads as well as his lay statements and medical evidence of the onset of his cervical spine and left knee symptoms; that the Veteran's current cervical spine and left knee disorders are not related to his period of active service are thus the most probative opinions in the present appeal. The Veteran is competent to testify to cervical spine and left knee symptoms, and there is no evidence that he is not credible. Jandreau, 492 F.3d 1372, 1376-77; Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006). The Veteran's cervical spine and left knee disorders have been diagnosed to include arthritis and such is a disability for which service connection may be granted on a presumptive basis. The Board thus considered whether there is evidence of arthritis within one year of separation from active service and whether there was evidence of continuous cervical spine and left knee symptoms since active service. Walker, 708 F.3d 1331. The earliest evidence of arthritis of the cervical spine is dated in 2001, and the earliest evidence of arthritis of the left knee is dated in 2005, both more than one year after separation from active service in 1987. The Board notes here that Dr. E. reported that an October 1998 treatment record indicated that the Veteran had mild degenerative arthritis. While the Board has found no such record, it concedes that left knee arthritis may have been present in as early as 1998; however, such was still not present within one year of separation from active service in 1987. It is most significant in this case that the Veteran does not assert continuous cervical spine and left knee symptoms since separation from active service in 1987 to the present. By his own statements, the earliest complaint of cervical spine symptoms is in 1989 and the earliest complaint of left knee symptoms are in 1995, considering the Veteran's January 2005 report of a ten-year history of left knee symptoms during military examination. In this regard, the Board has considered the Veteran's June 2008 statement wherein he reported that his musculoskeletal symptoms started in 1987 and 1989 through the present. Such represents an inconsistency in the record. The Board does not understand the Veteran's use of the word "and" when describing the onset of symptoms in this particular statement. The Veteran, to the Board, under oath, and during numerous instances of medical treatment, has not asserted that his symptoms began in 1987. The Board thus finds this particular statement to be of no probative value, as it is inconsistent with the Veteran's prior and subsequent lay statements and medical records. Dalton, 21 Vet. App. 23, at 38; Caluza, 7 Vet. App. 498, at 511, aff'd per curiam, 78 F.3d 604. The Board finds that the Veteran is not competent to opine as to the relationship between his current cervical spine and left knee disorders and his period of active service, specifically considering that there is no evidence, lay or medical, of in-service symptoms or continuous symptoms subsequent to separation from active service. There is no evidence that the Veteran has specific knowledge or skill in musculoskeletal injuries or diseases. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions); Kahana, 24 Vet. App. 428. The Board notes here that while the Veteran, in his June 20008 statement, cited his leg length discrepancy and childhood right knee problems as factors to consider in his conclusion that his left knee disorder is related to active service, he does not assert that either issue, the leg length discrepancy or the childhood right knee problems are related to active service. In this regard, the Veteran submitted internet articles, described above. A medical article or treatise can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222 (1999); Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). However, the medical articles submitted by the Veteran were not accompanied by the opinion of any medical expert linking his particular cervical spine and left knee disorders with his active service. Thus, the medical articles submitted by the Veteran are insufficient to establish the required medical nexus opinion for causation. Based on the forgoing, the Board concludes service connection must be denied. As reflected by the discussion above, the preponderance of the evidence is against the Veteran's claims. As such, the benefit-of-the-doubt rule does not apply, and the claims for service connection for cervical spine and left knee disorders must be denied. See 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a cervical spine disorder is denied. Service connection for a left knee disorder is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs