Citation Nr: 1317407 Decision Date: 05/28/13 Archive Date: 06/06/13 DOCKET NO. 10-04 178A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a left knee disorder, other than residuals of cold injury, claimed as secondary to a shell fragment wound of the left thigh. 2. Entitlement to an initial compensable evaluation for hypertension. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran served on active duty from June 1944 to June 1946. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, that denied service connection for a left knee disorder. A March 2012 rating decision granted service connection for hypertension and assigned an initial compensable disability evaluation, effective February 26, 2010. In a January 2011 decision, the Board denied the Veteran's claim for service connection for a left knee disorder. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (court). In a July 2012 Memorandum Decision, the court set aside the Board's decision and remanded the matter to the Board. The January 2011 Board decision also denied service connection for peripheral vascular disease of the upper and lower extremities. The court affirmed that portion of the Board decision and the issue is no longer on appeal. Also in January 2011, the Board remanded the Veteran's claims for service connection for a low back disorder, peripheral neuropathy of the upper and lower extremities, bilateral hearing loss, tinnitus, and arthritis of the low back, knees, and hands, as a result of cold injury, to the RO via the Appeals Management Center (AMC) in Washington, D.C., for further development. In a July 2011 decision, the Board granted service connection for bilateral hearing and tinnitus. At that time, it remanded the matter of entitlement to service connection for peripheral neuropathy of the upper and lower extremities to the RO via the AMC for further development. Then, in an April 2012 rating decision, the RO granted service connection for peripheral neuropathy of the upper and lower extremities. Thus, these matters are no longer on appeal Also, in July 2011, the Board denied entitlement to service connection for arthritis of the low back, knees, and hands as a result of cold injury, and a lumbar spine disorder, to include degenerative disc disease as secondary to cold injury and service-connected shell fragment wound to the left thigh. Consequently, these issues are no longer on appeal. In January 2013, the Board remanded the Veteran's claim for service connection for a left knee disorder, other than residuals of cold injury, claimed as secondary to a shell fragment wound of the left thigh, to the RO via the AMC for further evidentiary development. As discussed in the Introduction to the Board's January 2013 remand, during the course of this appeal, the Veteran's total disability rating increased from 40 to 80 percent. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009) (a request for a total rating based upon individual unemployability due to service-connected disability (TDIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate 'claim' for benefits but, rather, can be part of a claim for increased compensation). The Board noted that an increased rating was not currently on appeal, but found that a TDIU claim was raised by the record, and referred the matter to the RO for proper development and adjudication. However, there is no indication that the RO has yet considered the matter of entitlement to a TDIU and the claim is, again, referred to the RO for appropriate development and adjudication. The matter of entitlement to an initial compensable evaluation for hypertension is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC in Washington, DC. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The evidence of record preponderates against a finding that a left knee disorder, currently diagnosed as degenerative joint disease, had its onset or is otherwise related to the Veteran's military service and it is not due to a service-connected shell fragment wound of the left thigh; nor was degenerative joint disease of the left knee manifested to a compensable degree within one year of his discharge from active service. CONCLUSION OF LAW The criteria for service connection for a left knee disorder, other than residuals of cold injury, claimed as secondary to a shell fragment wound of the left thigh, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters in November and December 2007 and November 2008 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The November 2007 letter provided notice as to how VA assigns an appropriate disability rating or effective date, curing any timing defect. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of his claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All reasonably identified and available VA and non-VA medical records were obtained. A review of the Veteran's Virtual VA electronic file does not reveal any additional evidence regarding the claim for service connection for a left knee disorder. The Veteran was afforded a VA examination in November 2009 and the examination report is of record. As noted above, in January 2013, the Board remanded the Veteran's case to the RO for further development that included obtaining recent VA medical records and scheduling him for a VA examination. There has been substantial compliance with the Board's 2013 remand as he was scheduled for VA examination in April 2013 and VA medical records, dated to April 2013, were obtained. The Board finds that the April 2013 examination report is adequate for rating purposes as the claims file was reviewed, the examiner reviewed the pertinent history, examined the Veteran, provided clinical findings and diagnoses, and offered an etiological opinion with rationale from which the Board can reach a fair determination. The records satisfy 38 C.F.R. § 3.326 (2012). The April 2013 VA examination report makes up for the deficiencies in the November 2009 VA examination report. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA treatment and examination. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant 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). II. Factual Background and Legal Analysis The Board has thoroughly reviewed the record in conjunction with this case that includes the Veteran's service treatment records, VA and non-VA medical records and examination reports, dated in 1947 and from 1997 to 2013, and the Veteran's written statements in support of his claim. Although there is an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must 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). Under 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (to the effect that the theory of continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). Certain chronic diseases, including arthritis, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Nevertheless, the regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Moreover, case law has established that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the appellant's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). This is a direct service connection theory of entitlement. In addition, secondary service connection may 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). With regard to the matter of establishing service connection for a disability on a secondary basis, the court has held that there must be evidence sufficent to show that a current disability exists and that the current disability was either caused or aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Additionally, when aggravation of a non-service-connected disability is proximately due to or the result of a service-connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id.; see also 38 C.F.R. § 3.310(b). With regard to a claim for secondary service connection, the record must contain competent evidence that the secondary disability was caused by the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent evidence to the effect that the claim is plausible. However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of orthopedic pathology, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In written statements in support of his claim, the Veteran asserts that he has a left knee disorder, other than residuals of cold injury, due to his service-connected shell fragment wound of the left thigh. Upon review of the evidence of record, and after considering the laws and regulations applicable to the Veteran's claim, the Board finds that service connection is not warranted. Service treatment records do not discuss treatment for a left knee disorder. The records reflect that, in March 1945, the Veteran was treated for a shell fragment wound of the left thigh. When he was examined for discharge in June 1946, a knee abnormality was not noted. Post service, in a July 1946 rating decision, the RO granted service connection for a healed shrapnel scar of the left thigh that was assigned an initial noncompensable disability evaluation. A June 1947 VA examination report notes the Veteran's history of a gunshot wound to the left thigh in 1945. His only symptom was a pulling sensation in the back of his left thigh. The examiner noted that the Veteran had a 5 inch scar that was slightly adherent on the postero-medial aspect of the left thigh, post-operative, with minimal muscle damage to Muscle Group XV and no limitation of motion. The report does not discuss complaints or diagnosis of, or treatment for, a left knee disorder. A July 1947 rating decision granted a 10 percent rating for the Veteran's service-connected left thigh gunshot wound scar with damage to Muscle Group XV. A July 2002 report of VA examination of the Veteran's muscles includes his complaint of joint pain in his knees, hands, back, and hips that started approximately 20 years earlier. The impression included osteoarthritis of multiple joints affecting most likely the hands and lumbar spine area and most likely related to the aging process. X-rays of his hips were unremarkable except for minimal degenerative change (x-rays specific to the knee joints do not appear to have been taken). A May 2006 private medical record shows that the Veteran had osteoarthritis of the left knee. A July 2006 private magnetic resonance image (MRI) report of the Veteran's left knee includes an impression of a complex tear and severe degeneration of the medial meniscus, a moderate amount of joint effusion, and osteoarthritis, mild for his age. August 2006 private medical records reflect that the Veteran was initially evaluated in July 2006 with complaints of left knee pain dating to April 2006. An MRI was advised and showed a medial meniscus tear with joint effusion and arthritic changes for which arthroscopic examination was advised. The Veteran underwent left knee arthroscopic surgery in August 2006. A January 2008 VA examination report regarding the Veteran's left thigh scar includes his report of having some knee pain while sitting. According to the November 2009 VA examination report, the Veteran had some left knee soreness with knee pain primarily with walking long distances. He had arthroscopic surgery in 2006. The radiologic impression of an x-ray of his left femur taken at the time of examination was that there was a deformity involving the left ischium that suggested remote trauma. Specific views of the left hip with pelvis were recommended. There was no other significant abnormality. X-rays of the Veteran's left knee showed degenerative changes of the medial tibiofemoral joint and femoral patella joint. A clinical diagnosis of mild age-acquired degenerative joint disease of the left knee was rendered. The VA examiner stated that there was no indication of significant disability associated with the shell fragment wound of the left thigh and, thus, there would not be any kind of secondary connection to the knee. The examiner concluded that the Veteran's left knee disorder was not secondarily connected to the shrapnel wound. At a February 2011 VA neural disorders examination, the Veteran complained of an occasional aching in the left quadriceps when he walked. He was able to walk several blocks without any problems. He had some knee pain with sitting but no thigh pain. On examination, he had a slow non-antalgic gait. Pursuant to the Board's January 2013 remand, the Veteran underwent VA examination in April 2013. According to the examination report, the examiner reviewed the Veteran's medical records. The Veteran's history of shrapnel wound to the left thigh in 1945 was noted, and that he had a residual scar on the posteromedial area of the left thigh with a small metallic piece in the posterior area. The Veteran complained of an occasional ache in his quadriceps muscle when he walked. He had some pain in the knee, primarily with walking long distances. The Veteran denied flare ups and had no inflammatory joint disease. He had arthroscopic surgery in 2006 and had a femur x-ray that showed possible ischium deformity. The examiner performed a clinical evaluation and reviewed x-rays of the Veteran's pelvis, and left hip and knee. X-rays of his pelvis and left hip showed no acute fracture or dislocation but there was diffuse ostopenia. X-rays of the Veteran's right and left knees showed degenerative changes of the tibiofemoral joints and femoral patella joints of the left and right knees. The diagnosis was degenerative joint disease of the left knee that, in the VA examiner's opinion, was less likely than not (less than a 50 percent probability) caused by the Veteran's service-connected shell fragment wound of the left thigh. The VA physician-examiner explained that the prior examination showed no major problem with gait and the Veteran was able to walk for miles, as per the previous exam (it is unclear which earlier examination the physician refers). The shrapnel injury did not cause any gait abnormality or severe muscle injury either, (and there was) no evidence of atrophy. According to the VA examiner, the Veteran had degenerative joint disease of the left knee "most likely due to [the] aging process." Additionally, the VA examiner opined that the Veteran's left knee disorder was less likely as not (less than a 50 percent probability) aggravated (permanently worsened beyond its natural progression) by his service-connected shell fragment wound of the left thigh. The examiner reiterated that there was no gait abnormality, atrophy, or posttraumatic arthritis of the femur. The x-rays of the Veteran's hips in 2002 showed mild degenerative joint disease that was consistent with his age. X-rays were repeated due to suspected abnormality. The x-rays of the pelvis and left hip showed no deformity involving the Veteran's left ischium. The examiner stated that there was no abnormality found related to the Veteran's shell fragment wound of the left thigh. This physician further noted that there was no indication of significant disability of the thigh muscle. The Veteran had minimal age-acquired degenerative changes of the knee on x-ray. Additionally, the VA examiner explained that the Veteran's left ischium appeared normal in hip and pelvis x-rays. The examiner opined that the suspected remote trauma that resulted in a deformity involving the left ischium was not the same trauma associated with the Veteran's shell fragment wound to his left thigh. The examiner reviewed results of the x-rays taken in 2009 and 2013, and the small fragment in the posterior thigh tissue and noted that there was no injury to the femur or any other dystrophic calcification around there. According to the examiner, the ischium was not affected by the trauma "due to the position is remote and there was no trajectory of the bullet or shrapnel affecting this area". The VA examiner noted that the effect that the shrapnel had on the bloodstream in some occasions was that there was increased abnormal lead level but the small fragment was less likely to cause any intoxication. The shrapnel effect or the interaction with the hip and knee was less likely to be found in the present. The location of the fragment did not interfere with the range of motion of the Veteran's hip and knee. There was no evidence of any residual deformity as seen by the last x-rays. Further, the VA examiner commented that treatment of penetrating injuries to soft tissues did not require surgical excision of shrapnel. Metals usually remained inert and did not cause damage and, therefore, were left in soft tissue. In a few cases, delayed foreign bodies can present as localized cellulitis, abscess, or regional inflammatory process. The Veteran had no evidence of any soft tissue conditions. The VA examiner referenced "Delayed reaction to shrapnel retained in soft tissue." Injury 2005; 36(2); 275-81 (ISSN: 0020-1383) Eylon S; Mosheiff R; Liebergall M; Wolf E; Brocke L; Peyser A, Department of Orthopaedic Surgery, The Hadassah-Hebrew University Medical School, P.O. Box 12000, Jerusalem il-91120, Israel. The examiner also provided citations to other pertinent medical literature. Here, the service treatment records do not provide evidence of a left knee disorder in service. The Veteran had no treatment for a left knee disorder during military service. When he was evaluated for discharge in June 1946, no problems with the left knee were identified. The record unequivocally shows that there was no medical evidence of arthritis, or any other diagnosed disability, of the left knee, within one year after service. The first documented evidence of any type of left knee problem after service is from the VA examination report dated in 2002 that reflects the Veteran's history of knee pain that started 20 years earlier, and nearly 40 years after service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (to the effect that a lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming the Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). In short, no medical opinion or other medical evidence relating the Veteran's left knee disorder to service or any incident of service has been presented. As to the issue of secondary service connection, the only probative opinion of record is that of the April 2013 VA examiner who opined that the Veteran's degenerative joint disease of the left knee was less likely as not caused by or the result of the Veteran's service-connected shell fragment wound of the left thigh. According to the VA examiner, there was no evidence that the shrapnel wound caused a gait abnormality or severe muscle injury and no evidence of atrophy. The examiner opined that the Veteran had degenerative joint disease of the left knee most likely due to the aging process. The VA examiner provided a clear rationale to support that opinion and thus it is highly probative. There is no competent evidence to contradict this opinion. In the absence of any competent evidence of a chronic left knee disorder due to military service including service-connected disability, the Board must conclude that service connection for a left knee disability, other than residuals of cold injury, claimed as secondary to a shell fragment wound of the left thigh, is not warranted. In denying service connection as to the claim on appeal, the Board has considered the Veteran's contention that a relationship exists between his current left knee disorder, and military service. In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the court emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). The Veteran is competent to describe his observable symptoms, such as knee pain. However, he is not competent to make a statement of causation that is a medical determination. Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). To the extent he is claiming that knee pain problems have persisted since service, this is inconsistent with the overall record, which reflects that his knee symptomatology manifested after service. Again, the record fails to reflect that the Veteran was treated for a left knee disorder during military service and, in fact, a knee abnormality was not noted during service examination for discharge or on VA examination in 1947. The post service records show that the Veteran's left knee pain started in approximately the 1980s, nearly 40 years after his discharge from active service. See Maxson v. Gober, 230 F.3d at 1333; see also Mense v. Derwinski, 1 Vet. App. at 354. The Board recognizes that the absence of documented post-service treatment cannot, by itself, invalidate the Veteran's claims of continuous symptomatology. However, to the extent that the Veteran is claiming continuity of knee symptoms since service, he is not a reliable historian. He made no mention of his knee problems in 1946 during his service examination for separation, and examination of his knees at that time was normal. He has not explained why he failed to mention pertinent difficulty when examined pursuant to service requirements. The Veteran did not report having knee pain during his June 1947 VA examination and told the July 2002 VA examiner that his knee pain started approximately 20 years earlier but, in July 2006, a private physician reported that the Veteran's knee pain started in April 2006. The Board does not find that there is credible evidence of continuity of symptomatology present in this case. Moreover, the Veteran is not competent to state that he has degenerative joint disease of the left knee due to a service-connected shell fragment wound of the left thigh, or another orthopedic disorder. The clinical pathology of knee disorders is not readily recognizable by a layman, such as varicose veins or acne. See Jandreau v. Nicholson. Even medical professionals rely on laboratory test results, x-rays, and other diagnostic tools to diagnose knee disorders, including degenerative joint disease. Further, the April 2013 VA examiner, who reviewed the Veteran's in-service treatment records and his post service medical records, and performed a clinical evaluation, concluded that his degenerative joint disease of the left knee was less likely than not due to his service-connected shell fragment wound of the left thigh, and most likely due to the aging process. The VA examiner's opinion is entirely consistent with the November 2009 VA examiner's opinion. The Veteran's contentions are outweighed by the medical evidence and opinion of the April 2013 VA examiner that reflects that he did not have a left knee disorder related to his service-connected shell fragment wound of the left thigh. The Veteran's contentions as to etiology are not deemed competent and thus are not probative. Here, the Board is left with no documented complaints of left knee problems in service, no reported complaints or findings of a diagnosed left knee disorder after service until the 1980s, and a VA medical opinion to the effect that the Veteran did not have a left knee disorder due to his service-connected shell fragment wound of the left thigh. The questions involved regarding causation are medical in nature. As discussed above, the medical opinion of the April 2013 VA examiner (based on a review of the claims file and with knowledge of the Veteran's in-service duties and in-service complaints) was negative. In addition, to the extent that the Veteran has degenerative joint disease of the left knee, in its July 2011 decision, the Board denied his claim for service connection for arthritis of his knees and hands as secondary to cold injury. The Veteran did not appeal the Board's decision to the court and the decision is final. 38 C.F.R. § 20.1100 (2012). In sum, a clear preponderance of the objective and probative medical evidence of record is against the Veteran's claim for service connection for a left knee disorder, other than residuals of cold injury, claimed as due to a shell fragment wound of the left thigh, and his claim must be denied. The benefit-of-doubt rule does not apply when the Board finds that a preponderance of the evidence is against the claim. Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001). ORDER Service connection for a left knee disorder, other than residuals of cold injury, claimed as due to a shell fragment wound of the left thigh, is denied. REMAND As noted, in a March 2012 rating decision, the RO granted service connection for hypertension and awarded an initial noncompensable disability evaluation, effective from February 26, 2010. In a March 2012 written statement received by the RO in April 2012, the Veteran said that he was "requesting an increase in my service-connected compensation for hypertension". He referenced the RO's March 26, 2012 award notice letter and requested the RO to review private medical records he enclosed. The Board accepts the Veteran's statement as a notice of disagreement with the initial noncompensable rating assigned for his service-connected hypertension. However, the record does not reflect that the RO issued a statement of the case on this issue. Hence, the Board must remand this matter for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) Issue a statement of the case regarding the matter of entitlement to an initial compensable rating for hypertension. If, and only if, the appellant timely perfects an appeal, should this claim should be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs