Citation Nr: 1316096 Decision Date: 05/16/13 Archive Date: 05/29/13 DOCKET NO. 09-35 903 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for osteoarthritis and degenerative joint disease of the right knee (a right knee disability). 2. Entitlement to service connection for osteoarthritis of the left knee (a left knee disability), to include as secondary to a right knee disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L.M. Yasui, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from April 1965 to May 1968, and from May 1968 to October 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision of the Department of Veterans Affairs (VA) Hartford Regional Office (RO) located in Newington, Connecticut. In January 2013, the Board requested an opinion from a Veterans Health Administration (VHA) medical expert in orthopedics. In February 2013, the requested VHA opinion was incorporated into the record. In April 2013, the Veteran was provided with a copy of the VHA opinion. That same month, the Veteran submitted additional argument, which included redundant assertions of his in-service right knee injury; however, the submission also included a waiver of the right to an initial review of such evidence by the RO. As such, the Board will proceed to consider the case. See 38 C.F.R. § 20.1304(c) (2012). In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the file on the "Virtual VA" system to ensure a complete assessment of the evidence. FINDINGS OF FACT 1. The Veteran sustained an injury to the right knee in service. 2. Symptoms of a right knee disability were not chronic in service and were not continuous after service separation. 3. Symptoms a right knee disability did not manifest to a compensable degree within one year of separation from service. 4. A right knee disability is related to the injury noted in service. 5. The Veteran did not sustain an injury or disease of the left knee in service. 6. Symptoms of a left knee disability were not chronic in service and were not continuous after service separation. 7. Symptoms of a left knee disability did not manifest to a compensable degree within one year of separation from service. 8. A left knee disability is not causally or etiologically related to service. 9. A left knee disability is not caused by, or increased in severity beyond the natural progress of the disease by, the service-connected right knee disability. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for a right knee disability are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 2. The criteria for service connection for a left knee disability, including as secondary to a service-connected disability, are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a timely letter dated in December 2008, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection for a bilateral knee disability, as well as what information and evidence must be submitted by the Veteran, and what evidence VA would obtain. The December 2008 letter included provisions for disability ratings and for the effective date of the claims. With respect to notice regarding the service connection claim for a left knee disability on a secondary basis, while the Veteran was not provided this specific information, through continued representation, he has demonstrated actual knowledge of how to substantiate a claim for secondary service connection. In his notice of disagreement, the Veteran specifically stated that service connection for the left knee was being claimed as secondary to the right knee. At a Decision Review Officer hearing in May 2010, the hearing officer advised the Veteran that the left knee issue was for secondary service connection, and the Veteran answered that he had been overcompensating with the left knee because of right knee disability, that he put too much pressure on his left knee, and that he had degenerative joint disease in the left knee that he believed was the result of the right knee disability, and that he had cartilage removed from the left knee. The Veteran's representative also submitted a brief, dated April 2013, which provided the specific requirements needed to substantiate a claim for secondary service connection under 38 C.F.R. § 3.310(a) and Allen v. Brown, 7 Vet. App. 439 (1995). As such, the Veteran, through his representative, has demonstrated knowledge of the requirements regarding secondary service connection and had meaningful opportunities to participate in the adjudication of his claim (to include testifying in an informal RO hearing and undergoing a VA examination), thus curing any notice deficiency. With regard to the duty to assist, VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, a VA examination from June 2010, and the Veteran's statements. Attempts to obtain the Veteran's service treatment records from the National Personnel Records Center (NPRC) have been made. In May 2010, during the informal hearing before a decision review officer (DRO), the Veteran reported that some service treatment records are missing; however, upon further review of the claims file, it appears that these records have, in fact, been associated with the claims file. Indeed, the RO made no formal finding on the unavailability of the Veteran's service treatment records. The Board nevertheless recognizes that it has a heightened duty to explain its findings and conclusions to the extent that there are, in fact, missing records, and to carefully consider the benefit-of-the-doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992). Further, in this case, the Board is granting the claim for service connection of the right knee disability and the Veteran does not claim that a left knee disability was incurred in service or had onset in service. As such, further attempts to obtain potentially outstanding service treatment records are not warranted. See Sabonis v. Brown, 6 Vet. App. 426 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). Similarly, during the May 2010 DRO hearing, the Veteran also mentioned that private treatment records of his knees from Dr. J. and Dr. C., dated in 1971 to 1973, are unavailable as the doctors are either deceased or went out of business. Thus, any attempt to obtain these records would be futile. Id. The Veteran has also been afforded an opportunity for a VA medical examination in connection with his claim for service connection for right and left knee disabilities. 38 C.F.R. § 3.159(c)(4) (2012). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, as discussed in the January 2013 VHA request, the Board found the June 2010 VA examination to be inadequate as the examiner did not provide a rationale as to why it would be speculative to provide an opinion. See Jones v. Shinseki, 23 Vet. App. 382 (2010) (holding that an examiner's conclusion that an opinion would be speculative cannot be relied upon unless the examiner has explained the basis for such an opinion or the basis is otherwise apparent from the evidence of record). As such, the Board requested a VHA expert opinion in January 2013, which was provided in February 2013. The Board finds that the February 2013 VHA opinion and findings obtained in this case are adequate as they pertain to the claims for service connection. The VHA opinion considers all the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale for the opinions stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion as to the issues of service connection for a right knee and left knee disability has been met. 38 C.F.R. § 3.159(c)(4). As such, the RO has provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duties to notify and assist in the development of the claims. Service Connection - Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). 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. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). In this case, osteoarthritis and degenerative joint disease (as arthritis) are "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Service connection may be granted for a disability which is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310(a). "When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation." Allen v. Brown, 7 Vet. App. 439 (1995). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. at 303. Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau at 1372). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for a Right Knee Disability The Veteran contends that he injured his right knee during service while on combat patrol in Vietnam and also injured the right knee in service in 1970 during training and that he fell in a ditch. He asserts that is current right knee disability, which is diagnosed as arthritis, is related to an in-service right knee injury. The Board first finds that the Veteran has a current disability of the right knee. In December 2009, the Veteran's treating VA physician reviewed the results of knee X-rays with the Veteran and indicated a diagnosis of bilateral osteoarthritis and right knee degenerative joint disease. After a review of all the evidence of record, lay and medical, the Board finds that the weight of the evidence demonstrates that the Veteran sustained a right knee injury in service, but that symptoms of a right knee disability were not chronic during active service. He testified, during a May 2010 hearing before a DRO, that he first injured the right knee during his first period of service (from April 1965 to May 1968) when he was walking by a rice paddy on combat patrol in Vietnam and jumped off the side of a 50 caliber gun set-up. The Veteran testified that he tore up his right knee and sustained a puncture wound from a thorn. He stated that he walked 20 miles until the thorn was finally cut out by a corpsman. While the Veteran testified that he was offered the Purple Heart for this injury and refused to accept the award, a review of the relevant documents, to include the DD 214 from his first period of service indicate that the Veteran did not have combat service. Indeed, the Veteran does not allege that he was engaging in combat at the time of the claimed injury. In a discharge and reenlistment report of medical examination from May 1968, the Veteran had a normal clinical evaluation of his lower extremities, including strength and range of motion. The Veteran stated that another right knee injury was sustained during his second period of active service (from May 1968 to October 1970) when he was training for a physical fitness test and fell in a ditch. A service treatment report from February 1970, approximately seven months prior to service discharge, indicated the Veteran's complaint of pain in his right knee after he injured it approximately one month prior to seeking treatment. The report also indicated that the Veteran injured his knee when he stepped in a ditch while running. At the time of the injury, he was treated with Ace wraps, but the February 1970 treatment report noted that it was still causing pain. X-ray results taken at that time were negative. A service separation report of medical examination from September 1970 indicated a normal clinical evaluation of the Veteran's lower extremities, including range of motion and strength. The Board further finds that the weight of the evidence demonstrates that right knee disability symptoms have not been continuous since service separation in October 1970. As stated, the service separation examinations (from both periods of active service) revealed no clinical findings consistent with a right knee disability, or symptoms indicative thereof. The Veteran contends that he had right knee surgery in 1972 or 1973 and then again in 1993, the earliest of which is two years after service separation. A private treatment report from November 1999 did indicate a history of previous right and left knee surgeries; however, no dates were provided for those surgeries. The first, post-service treatment report of record indicating complaints of, and treatment for, a right knee disability is dated in February 2002. Another private treatment report from March 2002 indicated that the Veteran had surgery on his right knee. The Veteran himself testified that his right knee symptoms were not continuous, but were intermittent since service. See DRO hearing transcript at 12. The Board also finds that the weight of the evidence demonstrates that symptoms of a right knee disability were not continuous after service, including that a right knee disability did not manifest to a compensable degree within one year of service separation. The weight of the evidence demonstrates no right knee symptoms during the one year period after service, and no diagnosis or findings of arthritis of the right knee during the one year post-service presumptive period. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012) (degenerative arthritis is rated 10 percent when there is X-ray evidence of arthritis, pain, and at least noncompensable limitation of motion). The competent medical evidence shows the first diagnosis of osteoarthritis and degenerative joint disease of the right knee is in December 2009. Also for these reasons, the Board finds that a right knee disability did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for right knee osteoarthritis and degenerative joint disease as chronic conditions are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309(a). The Board next finds that the evidence is in equipoise on the question of whether the Veteran's current right knee disability is related to the right knee injury in service. In December 2009, the Veteran's treating VA physician reviewed the results of knee x-rays with the Veteran and indicated a diagnosis of osteoarthritis. At that time, the VA physician also opined that military injury was the initial factor of degenerative joint disease in the right knee; however, the VA physician did not provide any rationale for his medical conclusion. The opinion, which offers a bare conclusion, has no probative value. Miller, 11 Vet. App. at 348. In June 2010, the Veteran was afforded a VA examination of the knees. The Veteran reported to the VA examiner that the initial injury to his right knee occurred in service in February 1970 and made no mention of the alleged puncture wound to his right knee during his first period of service. After a complete physical examination, the VA examiner stated that she was unable to link the Veteran's right or left knee condition to his service without resorting to speculation. Although she cited post-service treatment reports of right knee injury and treatment, the VA examiner did not provide an adequate rationale as to why it would be speculative to provide an opinion. See Jones, 23 Vet. App. at 382. In light of the above, the Board found the June 2010 examination to be inadequate and requested a VHA medical opinion from an expert in orthopedics to assist in resolving the issue on appeal. In February 2013, an orthopedist provided a favorable medical opinion as to the etiology of the Veteran's right knee disability and is evidence in support of a finding that the right knee disability is related to service. The VHA physician opined that, after a thorough review of the medical records and relevant orthopedic literature, it is at least as likely as not that the disability of the right knee began during service or is related to the in-service injury. He explained that, while the X-rays of the Veteran's knees were negative pursuant to a 1970 right knee injury that occurred in service, generally, anterior cruciate ligament (ACL) tears will have negative X-rays as it is a soft tissue injury and not bony in nature. Further, he noted that current orthopedic literature supports that ACL deficient knees are at a much higher risk for development of meniscal tears, osteochondral injuries, and ultimately, degenerative joint disease. As such, there is competent medical evidence of a nexus between the Veteran's right knee disability and active service, including a detailed rationale for the conclusion. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). There is no other competent medical opinion of record against the claim which directly addresses the etiology of the Veteran's right knee disability. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for a right knee osteoarthritis and degenerative joint disease have been met. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for a Left Knee Disability The Veteran contends that his left knee disability is secondary to the right knee disability. As adjudicated above, the Veteran is service-connected for a right knee disability. He has contended in writing and at the DRO hearing that the right knee disability has caused him to overcompensate with the left knee, which he believes caused the left knee disability. After a review of all the evidence of record, lay and medical, the Board first finds that the Veteran has a current disability of the left knee. Noted above, in December 2009, the Veteran's treating VA physician reviewed the results of knee X-rays and rendered a diagnosis of bilateral osteoarthritis. The Board finds that the weight of the evidence demonstrates that the Veteran did not sustain any injury or disease of the left knee, and that left knee disability symptoms were not chronic in service. In fact, the Veteran himself has not claimed that left knee symptoms manifested in service or had onset in service. In a discharge and reenlistment report of medical examination from May 1968, the Veteran had a normal clinical evaluation of his lower extremities, including strength and range of motion. Additionally, a service separation report of medical examination from September 1970 indicated a normal clinical evaluation of the lower extremities, including range of motion and strength. The Board further finds that the weight of the evidence demonstrates that left knee disability symptoms have not been continuous since service separation in October 1970. As stated, the service separation examinations (from both periods of active service) revealed no clinical findings consistent with a left knee disability, or symptoms indicative thereof. A private treatment report from November 1999 did indicate a history of previous right and left knee surgeries; however, no dates were provided for those surgeries. The first, post-service treatment report of record indicating complaints of, and treatment for, a left knee disability is dated in February 2002. Such absence of post-service findings, diagnosis, or treatment for decades after service is one factor that tends to weigh against a finding of continuous left knee symptoms after service separation. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (holding that the Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor to consider as evidence against a claim of service connection). Indeed, during the May 2010 DRO hearing, the Veteran himself did not testify as to any continuing symptomatology of the left knee since separation from active service. See DRO hearing transcript. The Board also finds that the weight of the evidence demonstrates that a left knee disability of arthritis did not manifest within one year of service separation, including to a compensable degree. The weight of the evidence demonstrates no left knee symptoms during the one year period after service, and no diagnosis or findings of arthritis of the left knee during the one year post-service presumptive period. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (degenerative arthritis is rated 10 percent when there is X-ray evidence of arthritis, pain, and at least noncompensable limitation of motion). The competent medical evidence shows the first diagnosis of left knee osteoarthritis is in December 2009. Because left knee arthritis did not manifest to a compensable degree within one year of service separation, the presumptive provisions for left knee osteoarthritis as a chronic condition are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309(a). The Board next finds that the weight of the evidence further demonstrates that the Veteran's left knee disability is not proximately due to, or aggravated by, the service-connected right knee disability, and is not otherwise related to service. During the June 2010 VA examination, the Veteran reported that he had left knee cartilage repair but was unsure of the surgery date. After a complete physical examination, the VA examiner stated that she was unable to link the Veteran's right or left knee condition to his service without resorting to speculation. The VA examiner did not provide an adequate rationale as to why it would be speculative to provide an opinion; thus, the June 2010 VA examination is inadequate for rating purposes. See Jones at 382. The evidence weighing against a finding that the left knee disability is proximately due to, or aggravated by, the service-connected right knee disability, or is otherwise related to service, is the February 2013 VHA expert medical opinion. The VHA physician, an orthopedist, opined that, after a thorough review of the medical records and relevant orthopedic literature, it is less likely than not that the Veteran's left knee disability is caused or aggravated by the right knee disability. The VHA physician explained that there is no medical evidence to support the notion that right knee injuries or any resulting gait abnormality cause or aggravate the uninjured contralateral left knee. Further, he noted that patients with idiopathic knee degenerative joint disease are commonly affected bilaterally; however, this is not a reflection of causation, but instead of age and genetic background. In citing the most applicable orthopedic literature, which demonstrated that the condition of the contralateral knee is the most important factor in the long term outcome of the knee, not the presence of arthritis in the other knee, the VHA physician concluded that the medical evidence does not support the finding that having an injury and subsequent arthritis in one knee would adversely affect the other knee. The VHA physician has orthopedic medical expertise, had adequate information on which to base his medical opinion, to include specific orthopedic literature, and provided an adequate rationale for the conclusion based on medical principles. For these reasons, the Board affords the April 2013 VHA physician's medical opinion great probative weight. Although the Veteran has asserted that his right knee disability caused or aggravated his left knee disability, the Board recognizes that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, 581 F.3d at 1316 (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau, 492 F.3d at 1372). In this case, the causes of the Veteran's left knee disability involve complex medical etiological questions because they pertain to the origin and progression of the Veteran's left knee arthritis. The Veteran is competent to relate symptoms of a left knee disability that he experienced at any time, but he is not competent to opine on whether there is a link between the current left knee disability of arthritis and the right knee disability or active service because such conclusions regarding causation and aggravation require specific, highly specialized, medical knowledge and training regarding the unseen and complex processes of the musculoskeletal system, knowledge of the various risk factors and causes of arthritis, specific clinical testing for arthritis, knowledge of likely date of onset and ranges of progression of arthritis that the Veteran is not shown to possess. See Rucker, 10 Vet. App. at 74 (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). Here, the theory of secondary service connection turns on the question of whether there exists a secondary medical relationship between the current left knee disability and the service-connected right knee disability. The only probative medical opinion of record that directly addresses the likelihood of a secondary relationship between the left knee disability and the right knee disability, which was provided by the February 2013 VHA orthopedist, demonstrates that there is no secondary relationship between the left knee disability and the right knee disability on either a causation or aggravation basis and weighs against the claim. Based on the evidence of record, the weight of the competent and credible evidence demonstrates no relationship between the Veteran's current left knee disability and the right knee disability or active duty service, including no credible evidence of chronic symptoms of a left knee disability in service, of left knee arthritis to a compensable (10 percent) degree within one year of service separation, or continuity of symptomatology of a left knee disability since service. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a left knee disability on both a secondary and direct basis, including presumptively as a chronic disease, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for right knee osteoarthritis and degenerative joint disease is granted. Service connection for a left knee disability, to include as secondary to the service-connected right knee disability, is denied. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs