Citation Nr: 1316606 Decision Date: 05/21/13 Archive Date: 05/29/13 DOCKET NO. 09-32 855 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for right knee disability. 2. Entitlement to service connection for left knee disability, claimed as secondary to right knee disability. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from March 1999 to August 2004. Service in Southwest Asia is indicated by the record. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, which denied the Veteran's claims. During the course of the appeal, the Veteran moved to Indiana; original jurisdiction now resides in the Indianapolis, Indiana RO. This matter was previously before the Board in July 2011 and was remanded for further development. The Veteran was scheduled to appear at the Indianapolis RO to have a personal hearing with a Veterans Law Judge. The Veteran failed to appear for said hearing, and he has not since asked for it to be rescheduled. Accordingly, the hearing request is deemed withdrawn. See 38 C.F.R. § 20.704(d) The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the appellant's claims. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. The evidence of record is against a finding that the Veteran's right knee disability is related to his active duty service. 2. The evidence of record is against a finding that the Veteran's left knee disability is related to active duty service, or a service-connected disability CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee disability are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. The criteria for service connection for a left knee disability, including on a secondary basis, are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist With regard to the claims for service connection, VA has met the duty to notify and assist the claimant in substantiating this claim for VA benefits, as provided by the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record that is necessary to substantiate the claim. Proper notice will inform the Veteran of what evidence VA will seek to provide, and of what evidence the claimant is expected to provide, in accordance with 38 C.F.R. § 3.159(b)(1) (2011). Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information regarding the disability rating and effective date for the award of benefits if service connection is awarded. Id. at 486. The U.S. Court of Appeals for the Federal Circuit previously held that any errors in notice required under the VCAA should be presumed to be prejudicial to the claimant unless VA shows that the error did not affect the essential fairness of the adjudication. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Under Sanders, VA bore the burden of proving that such an error did not cause harm. Id. In the case Shinseki v. Sanders, 129 S.Ct. 1696 (2009), however, the U.S. Supreme Court held that the Federal Circuit's blanket presumption of prejudicial error in all cases imposed an unreasonable evidentiary burden upon VA. Rather, in Shinseki v. Sanders, the Supreme Court suggested that determinations concerning prejudicial error and harmless error should be made on a case-by-case basis. Id. As such, in conformance with the precedents set forth above, on appellate review the Board must consider, on a case-by-case basis, whether any potential VCAA notice errors are prejudicial to the claimant. Here, VA satisfied the VCAA duty to notify by way of letters sent to the Veteran, including in July 2011, which fully addressed all of the notice elements. Through that letter, VA informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. VA also informed him that his service connection claim must be supported by evidence indicating a current disability, evidence that the injury or disease was incurred or aggravated during service, and medical evidence of a nexus between the current disability and the in-service injury or disease. VA informed him that VA would seek to provide federal records and that it was his responsibility to support his claim with appropriate evidence, though VA would help him obtain records from any non-federal sources. VA also informed the Veteran that service connection can be awarded on a secondary basis, when a disorder is either caused or aggravated by a service-connected disability. That letter also included notice with respect to the Dingess requirements of the type of evidence necessary to establish an effective date. Although the July 2011 letter was sent after the initial adjudication of the claims in the January 2008 rating decision, the Veteran's claims were subsequently readjudicated by the agency of original jurisdiction (AOJ) in June 2012. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and VA has complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in obtaining any outstanding records of identified VA or private medical treatment relevant to his claim, and affording him an examination when appropriate. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has a duty to assist the Veteran in developing his claim. This duty includes assisting the Veteran in obtaining any outstanding records of identified VA or private medical treatment relevant to his claim, and affording him an examination when appropriate. With regard to records, VA has associated with the claims folder the Veteran's service treatment records and pertinent VA medical records. The RO associated VA medical records with the claims folder. Although the Veteran reported, in his March 2009 VA Form 21-4142 that he was making a future appointment with his knee doctor with VA in Crown Point, Indiana. The Board notes that that facility is part of the Chicago VA medical center and that records of appointments with that center do not indicate such an appointment in the months following March 2009. The Veteran also identified private medical records for the knee, which the RO has since obtained and associated with the claims file. As ordered by the Board in the July 2011 Board remand, the AOJ provided the Veteran with updated and corrected VCAA notice (as discussed above) and requested that he provide information regarding his medical treatment. The Veteran has not indicated that there exist any records of VA or private VA medical treatment relative to this claim that are not already in the claims file, but did provide additional private medical records that are now associated with the claims file. Additionally, the AOJ obtained a VA medical opinion, as ordered by the Board, to address the question of the Veteran's right knee disability. The Veteran underwent VA examinations in January 2008 and July 2009. His claim was subsequently reviewed for a medical opinion in August 2011. In a March 2013 informal hearing presentation, the Veteran representative indicated a new VA examination is necessary because it did not discuss lay statements by the Veteran of continuity of symptoms. VA is only required to provide a medical examination if, after taking into account all of the information and medical or lay evidence, the evidence is insufficient for a decision to be made on a claim. 38 U.S.C.A. § 5103(d)(2). There is no duty on the part of VA to provide another medical examination. As in Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003), the appellant has been advised of the need to submit competent medical evidence to support his claim or evidence to show why a new examination is warranted. The Veteran has repeatedly been invited to submit substantiating evidence. The Veteran has not done so, and no other supportive evidence has otherwise been obtained. The Board notes that the Veteran submitted a March 2011 private medical record with a new diagnosis of a right meniscal tear; however, those medical records did not contain any medical nexus opinion evidence regarding the claim. As such, to the extent that the August 2011 VA examiner may not have considered that evidence, the Board finds that the Veteran was not prejudiced by the failure to consider such evidence as it does not pertain to the question of the Veteran's in-service injury. Here, as in Wells, the record in its whole, after due notification, advisement, and assistance to the appellant under the VCAA, has no competent evidence to suggest that another VA examination is necessary to make a decision on this claim. Additionally, as will be further explained in the decision below, the Board does not find the Veteran's statements as to continuity to be credible. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Applicable Law Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Generally for service connection, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004) (citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); Caluza v. Brown, 7 Vet. App. 498, 505 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)(table). Service connection may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that a Veteran had a chronic condition in service or during the applicable presumptive period. Certain chronic diseases, to include malignant tumors, will be presumed to have been incurred in service if manifested to a compensable degree (meaning to at least 10-percent disabling) within one year after service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b): (a) by evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, by evidence of continuity of symptomatology. Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448(1995) (en banc). The Board notes that there was an amendment to the provisions of 38 C.F.R. § 3.310 in 2006. See 71 Fed. Reg. 52744 -47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is rated. The new provisions also require that service connection not be awarded on an aggravation basis without establishing a pre- aggravation baseline level of disability and comparing it to current level of disability. The purpose of the regulatory change was to implement the requirements of Allen v. Brown, 7 Vet. App. 439(1995). In the comments to the new regulation, the changes were intended to place a burden on the claimant to establish a pre-aggravation baseline level of disability for the non-service-connected disability before an award of service connection based on aggravation may be made. Factual Background The December 1998 enlistment examination included a finding of normal lower extremities, although the examiner noted a right knee scar. On January 25, 2001, the Veteran complained of right knee pain for nine days after bumping his knee during an obstacle course. The examiner found no deformity, edema, ecchymosis, erythema, laceration, abrasion. The examiner also found positive mild TTP lateral aspect of the knee. The following day, the Veteran complained of difficulty bending his knee and injuring himself during an obstacle course. The Veteran reported that he had a surgical history of the knee. The examiner found a sprain. An April 2002 X-ray report of the right lower leg documented no evidence of a fracture, inflammatory or neoplastic changes. In his March 2005 post-deployment examination report, the Veteran complained of swollen, stiff or painful joints. The June 2004 separation examiner noted the right knee scar, but found the lower extremities to be normal. On his report of medical history, the Veteran reported knee trouble and noted that he had injured his right knee prior to service and reinjured it in Ranger school. Following the Veteran's August 2004 separation from service, a November 2004 private medical record from Hindsdale Orthopaedic documents treatment for the left knee. The Veteran complained of left knee soreness for three weeks, without injury. The examiner found normal X-rays and a possible torn meniscus. A January 2008 VA joints examination included an examination of the left knee and a review of private medical and service treatment records. The Veteran complained of the left knee giving out occasionally and pain on certain activities. He reported a hyperextension injury to his left knee while walking with gear on uneven terrain in 2000. The VA examiner diagnosed the Veteran with left knee strain and found it less likely than not to be due to service. In July 2009, the Veteran underwent a right knee VA examination, which included a review of the claims file. The Veteran reported an original right knee injury at the age of 12, when he ran into a glass door and subsequently had glass debris removed from his knee. He reported it was a superficial injury and he did not have any surgery or any other problem. He also reported subsequent difficulty running due to pain and swelling and hyperextending on a jump. The examiner also noted that X-rays that day showed no fractures, dislocations or bony abnormalities. The examiner found a "very mild right knee sprain" and that X-ray is normal. The July 2009 VA examiner opined that it was not at least as likely as not that the Veteran's pre-existing right knee condition was permanently worsened by service beyond its natural progression, as the Veteran only had a very mild sprain. A March 2011 MRI report documented that the Veteran had a sports injury and pain. The examiner found posterior horn medial meniscal tear, sprain of the proximal medial collateral ligament, small focus of osteionecrosis in the interspinous region and small joint effusion. The attached treatment record noted that the Veteran had right knee pain, after hyperextending it three weeks previously. The AOJ obtained a new medical opinion in August 2011, which did not include an examination. The examiner noted that the Veteran reported a right knee condition that pre-existed service and reinjured his knee in Rangers school. The examiner noted that the July 2009 VA examination report of the pre-service glass door injury was consistent with lacerations to the knee and that the Veteran did not have ongoing right knee problems following convalescence and the removal of the foreign body. The examiner noted that such would be consistent with a self-limited condition that resolved and would not cause/worsen a knee condition that developed later. The August 2011 VA medical opinion provider opined that it was at least as likely as not that the Veteran's pre-service (pre-existing) right knee injury did not cause or worsen his present right knee condition. The August 2011 VA medical opinion provider further noted that the service treatment records indicated that the Veteran had a right lateral collateral ligament sprain in service (with positive varus stress otherwise within normal limits), following an obstacle course injury, and discussed the Veteran's treatment in service. He noted that no knee brace or other form of immobilization was provided, no surgery performed and there was no record of ongoing care for the right knee. He concluded that the in-service sprain must have been of low grade. He also noted the current knee findings from the July 2009 VA examination, including an impression of very mild right knee sprain. He further noted review of X-rays and found no appreciable degenerative changes, OCD or loose bodies, evidence of remote or recent fracture, or soft tissue calcifications. The August 2011 VA medical opinion provider disagreed with the July 2009 VA examiner's impression of mild right knee sprain. He noted that the Veteran had a remote history of a low-grade lateral collateral ligament sprain and that condition "has long since healed and no longer exists. Without a history of recent trauma I am not convinced one can have a knee sprain, rather, only residuals of the sprain may be present." The August 2011 VA medical opinion provider further noted that various grades of ligamentous strains and described how the grades are determined, in detail. He then explained that the July 2009 VA examination record was "entirely inconsistent with a strain. There is no tenderness over any ligament examined and there is no residual instability." He then found that the Veteran's anterior knee pain was mostly likely caused by a patellar femoral syndrome and possibly patellar tendinopathy. He noted physical findings of tenderness, patellar tendon insertion, crepitations and mild tracking. He further noted that "a knee sprain would be an uncommon cause of the anterior knee pain with the exception being injury to the medial patellofemoral ligament (which veteran did not have)". He continued to explain that maltracking would be better phrased as patellar malalignment which may consist of patellar subluxation and/or tilt...common cause of a patella-femoral syndrome and is usually congenital/developmental condition (residuals of a patellar dislocation/disruption of medial patellofemoral ligament both of which veteran has no history of physical findings to support) would be an exception. The August 2011 VA medical opinion provider then explained that patellar malalignment/patellofemoral (pain) syndrome/patellar tendinopathy is not caused by an injury to the lateral collateral ligament of the knee, but by a mechanism of injury that is entirely different. He then opined that it is less likely than not that the Veteran's present knee condition patellofemoral syndrome/patellar tendinopathy was caused or worsened beyond what one would expect from its natural history by the Veteran's in-service injury to the right knee (sprain lateral collateral ligament). Analysis The Veteran contends that he injured his right knee while performing an obstacle course during his in-service training. During his July 2009 VA examination the Veteran reported a pre-service right knee injury. He further contends that he developed a left knee disability either due to service or secondary to his right knee disability. Right Knee Disability The Board initially notes that the December 1998 enlistment examination report did not indicate a pre-existing right knee disability (though it did note scars of the right knee); the Veteran has repeatedly reported a pre-service injury that involved running into a glass door, without residual problems. A veteran is presumed in sound condition except for defects noted when examined and accepted for service. Clear and unmistakable evidence that the disability existed prior to service and was not aggravated by service will rebut the presumption of soundness. 38 U.S.C.A. § 1111; VAOPGCPREC 3- 2003. A pre-existing disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. In this case, the Veteran has reported a pre-existing injury to the right knee. The August 2011 VA medical opinion provider noted the pre-service injury of running into a glass door and having debris removed from it. However, that examiner found that injury to be consistent with a self-limited condition that resolved and would not cause/worsen a knee condition that developed at a later time. Additionally, as will be explained in the decision herein, the Board has found the August 2011 VA medical opinion to be the most probative in regards to the current claims. Given that the December 1998 enlistment examiner did not find a right knee disability and that the August 2011 VA medical opinion provider found that the pre-service injury was a self-limited condition that resolved prior to service, and giving the Veteran the benefit of the doubt, the Board finds that the Veteran should be presumed to have been in sound condition in regards to his right knee. In regards to a right knee disability, the first two criteria for service connection are met. First, the Veteran has alternating current diagnoses of very mild right knee sprain in the July 2009 VA examination report), patellofemoral syndrome/patellar tendinopathy (based on the July 2009 VA examination report) in the August 2011 VA medical opinion, and the March 2011 MRI report of posterior horn medial meniscus tear, sprain of the proximal medial collateral ligament, small focus of ostonecrosis in the interspinous region and small joint effusion. The second criterion has also been met, as the Veteran has a documented right knee injury in service. The January 2001 service treatment records document complaints of, or treatment for, the right knee, after the Veteran bumped it while going through an obstacle course. The Board finds that the Veteran has not met the criterion of service connection. There is no medical evidence of a nexus between the current disability and the in-service injury or disease, and the competent medical opinions which address this question found that there was not a connection between the Veteran's current right knee disability and service. Two medical opinions are of record in regards to the right knee. Neither medical opinion supports the Veteran's claims. The July 2009 VA examiner noted normal X-rays that day, which showed no fractures, dislocations or bony abnormalities and diagnosed a "very mild right knee sprain". The examiner opined that it was not at least as likely as not that the Veteran's pre-existing right knee condition was permanently worsened by service beyond its natural progression, as the Veteran only had a very mild sprain. The August 2011 VA medical opinion provider disagreed with the July 2009 VA examiner's impression of mild right knee sprain. That the August 2011 VA medical opinion provider found that the pre-service injury had long since healed and no longer exists. He then found that condition without a history of recent trauma; he was not convinced that a knee sprain could exist. Rather only residuals of the sprain may be present. The August 2011 VA medical opinion provider explained that patellar malalignment/patellofemoral (pain) syndrome/patellar tendinopathy was not caused by an injury to the lateral collateral ligament of the knee, but by a mechanism of injury that is entirely different. He then opined that it is less likely than not that the Veteran's present knee condition of patellofemoral syndrome/patellar tendinopathy was caused or worsened beyond what one would expect from its natural history by the Veteran's in-service injury to the right knee (sprain lateral collateral ligament). In assessing medical evidence, whether an examiner provides a basis for a 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 examiner's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-89 (2000). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Sklar v. Brown, 5 Vet. App. 140 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); Swann v. Brown, 5 Vet. App. 229, 232 (1993). In the present case, the Board finds the August 2011 VA medical opinion to carry the most weight. That medical opinion provider had access to the most medical evidence of record, including the July 2009 VA examination report. He also provided the most thorough, logical, and complete medical opinion. He fully explained how he reached his conclusions, including a discussion of the service treatment records and the medical principles he used in making the opinion. Additionally, in addition to be a medical doctor, he is specifically an orthopedic consultant, which indicates that he specializes in orthopedic matters. The Veteran has claimed that he experienced trouble with his right knee in service, and that his complaints have continued to this day. While the Veteran is competent to testify as to experiencing right knee pain during service and since such time, the Board finds that such statements are not credible because they are outweighed by the remainder of the evidence of record and were made under circumstances indicating bias or interest. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. In this regard, the Board observes that although January 2001 service treatment records document complaints of, or treatment for, a right knee sprain the subsequent records do not document continued treatment for that injury. In his June 2004 report of medical history, the Veteran reported knee trouble and noted that he had injured his right knee prior to service and reinjured it in Ranger school. The June 2004 separation examiner, however, found the lower extremities to be normal. Following his August 2004 discharge from service, the record does not document any treatment for the right knee for the next five years, though the Veteran sought treatment for the left knee during that time period. Indeed, a November 2004 private medical provider specifically noted that the right knee was asymptomatic, indicating that the right knee did not have continuous pain. Additionally, the Veteran did not filed a claim for service connection for the right knee until April 2007, years following his discharge from service. Moreover, the Veteran has provided an inconsistent medical history pertaining to his general physical condition. In his January 2008 VA examination for the joints (for disabilities other than the right knee), the Veteran specifically denied a history of a motor vehicle accident. However, numerous private medical records document a March 2007 motor vehicle accident and subsequent treatment for it. For example, an April 2007 record by chiropractor S. Battalglia noted that the Veteran was rear ended, his foot was knocked off the brake pedal and that the vehicle incurred moderate damage. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). The Board cannot ignore the fact that the Veteran has provided inconsistent statements and altered his medical history. Therefore, the Veteran's current statements made in connection with his pending claim for VA benefits, to include the claim of chronicity, are inconsistent with the contemporaneous evidence of record. Consequently, the Board finds that the Veteran's statements regarding experiencing chronic right knee pain since service are not credible. The only evidence provided supporting the claim are in statements from the Veteran himself. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, i.e., the etiology of a knee disability, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In this regard, the question of causation involves a medical subject concerning an internal physical process extending over a period of several years. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is not probative evidence. See Jandreau, supra; see also 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). As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). The Veteran's claim for service connection for a right knee disability is denied. Left Knee Disability The Veteran contends, as in his April 2007 VA Form 21-4142, that he developed a left knee disability secondary to his right knee disability. During his January 2008 VA examination, he alternatively contended that he developed a left knee disability in service, from walking with gear on uneven terrain in 2000. As an initial matter, service-connection for a right knee disability is not in effect. Service connection on a secondary basis may only be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). As such, service connection for a left knee disability secondary to the non-service-connected right knee disability is not warranted. In regards to service connection on a direct basis, the Veteran has met the first element of the existence of a present disability for service connection. The January 2008 VA examiner diagnosed the Veteran with a left knee strain. The most probative evidence, however, does not show that the second element of service connection, an in-service incurrence or aggravation of a disease or injury, has been met. During his January 2008 VA examination, the Veteran reported hyperextending his knee while walking on uneven terrain in service and seeking treatment following that injury. He further reported that to have been his only left knee injury. Although the Veteran is competent to testify as to experiencing left knee pain during service and since such time, the Board finds that such statements are not credible as they are outweighed by the remainder of the evidence of record and were made under circumstances indicating bias or interest. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See Caluza, supra. Although the Veteran claims that he injured his left knee in 2000 and sought treatment for that injury, the service treatment records do not document any such complaints of, or treatment for, the left knee. Indeed, in his June 2004 report of medical history, the Veteran discussed a right knee injury, but not a left knee injury. The first indication of a left knee disability is shown following his August 2004 discharge from service. A November 2004 private medical record from Hindsdale Orthopaedic, documents that the Veteran complained of left knee soreness for three weeks, without injury. Furthermore, the Veteran has provided an inconsistent medical history pertaining to his left knee. In his January 2008 VA examination, the Veteran specifically denied a history of a motor vehicle accident. In contrast, numerous private medical records document a March 2007 motor vehicle accident and subsequent treatment. Rucker, supra.; See Williams, supra. (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). The Veteran has also been inconsistent in his report of how he injured his left knee. In his April 2007 VA Form 21-4142, he claimed that due to his compensating for his right knee injury he injured his left knee by applying extra weight and pressure on it. He did not indicate that he actually injured his left knee in service, but reported such an injury to his January 2008 VA examiner. The Board cannot ignore the fact that the Veteran has altered his medical history and his report of how he injured his left knee. Therefore, the Veteran's current statements made in connection with his pending claim for VA benefits, to include any claim of chronicity, are inconsistent with the contemporaneous evidence of record. Consequently, the Board finds that the Veteran's statements regarding experiencing chronic left knee pain since service are not credible. Even if, for the sake of argument, the Board were to find that the Veteran had an in-service left knee injury, the Veteran's claim would still fail as there is no medical evidence of record to support his contention that a current left knee disability was caused or aggravated by service. The only medical evidence addressing the etiology of the Veteran's left knee disability is the opinion of the VA examiner that provided both the January 2008 joints and spine VA examinations. Although the VA examiner diagnosed the Veteran with left knee strain, he found that after extensive review of the civilian and service treatment records, there was no evidence to support the Veteran's contentions that the left knee condition was related to service. The examiner noted that the record supported finding that the Veteran had access to medical treatment in service. The examiner further noted the Veteran's discrepancies in reporting his medical history. The VA examiner opined that the left knee condition is less likely than not related to his military service. The only evidence provided supporting the claim are in statements from the Veteran. Although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, as to the specific issue in this case, i.e., the etiology of a knee disability, falls outside the realm of common knowledge of a lay person. See Jandreau, supra (lay persons not competent to diagnose cancer). In this regard, the question of causation involves a medical subject concerning an internal physical process extending over a period of several years. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's opinion is not probative evidence. See Jandreau, supra; see also Woehlaert, supra. (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). As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. Gilbert, supra. The Veteran's claim for service connection for a left knee disability is denied. ORDER Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs