Citation Nr: 1318756 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 05-06 609A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for osteoarthritis of the left knee. 2. Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder. 3. Entitlement to an effective date prior to May 30, 2003, for an award of service-connection for hypertension. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran had active service from September 1977 to March 1985. The Veteran is entitled to VA benefits for the period from September 21, 1977, to September 21, 1981; however, VA benefits are precluded for the period of service from September 22, 1981, to March 14, 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs Regional Office (RO) in Newark, New Jersey. The case was previously before the Board in October 2008. At that time, the issues of service connection for osteoarthritis of the left knee and an acquired psychiatric disorder were remanded for further development of the evidence. The Board also denied an effective date earlier than May 30, 2003, for an award of service connection for hypertension. The Veteran appealed the Board's denial of an earlier effective date to the United States Court of Appeals for Veterans Claims (Court), and the Board's decision was vacated pursuant to a February 2010 Order, following a Joint Motion for Remand (JMR). The parties requested that the Court vacate the Board's October 2008 decision regarding the denial of an effective date earlier than May 30, 2003, and remand the matter so that the Board could consider whether correspondence received by VA in 2000 that referenced a heart condition could constitute a claim of service connection for hypertension. The Court granted the joint motion and remanded the case to the Board. The issue of service connection for an acquired psychiatric disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran did not have a left knee disability prior to his entry into service. 2. The Veteran sustained an injury of his left knee and had complaints of left knee pain during service. 3. Arthritis of the left knee was not manifested to a degree of 10 percent within one year of the end of the Veteran's recognized period of active duty. 4. A chronic left knee disability was not evident during a recognized period of service or until many years thereafter and is not shown to have been caused by any in-service event. 5. In July 2000, the Veteran submitted correspondence that was associated with a medical record showing a preliminary diagnosis of hypertension on an emergency room treatment record dated in October 1999; this diagnosis was not supported by follow-up examination in the hospital when the discharge diagnosis of hypotension was made. The July 2000 correspondence did not mention a claim of service connection for heart disease or hypertension. 6. The Veteran submitted a claim of service connection for a heart condition on October 13, 2000, and he continuously prosecuted that claim until service connection for hypertension was awarded in an August 2003 rating decision. 7. Service connection for hypertension was awarded based in part on service treatment records showing that the Veteran developed hypertension while in active service. CONCLUSIONS OF LAW 1. A chronic left knee disability was neither incurred in nor aggravated by service nor may arthritis of the left knee be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. The criteria for an effective date of October 13, 2000, for the award of service connection for hypertension have been met. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. §§ 3.155, 3.400(b)(2)(i) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 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 requirements apply to all five elements of a service connection claim: 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). 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). As an initial matter, given the granting of an earlier effective date for hypertension herein, any further development or notification action under the Veterans Claims Assistance Act of 2000 (VCAA) would not avail the claimant with respect to that claim. The Veteran was advised of VA's duties to notify and assist in the development of the knee claim prior to the initial adjudication of the claim. September 2001, April 2002, March 2006, and November 2008 letters explained the evidence necessary to substantiate the claim, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. The March 2006 and November 2008 letters also informed the Veteran of disability rating and effective date criteria. The Veteran has had ample opportunity to respond and supplement the record. With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records, including records utilized in a claim for disability benefits by the Social Security Administration (SSA), have been secured. The Veteran was afforded a VA medical examination of the knee, most recently in March 2010. In addition, the Veteran's claims file has been reviewed by representatives of the director of the Veterans Health Administration (VHA) for an opinion regarding the etiology of his left knee arthritis. The Board finds that the opinions obtained are adequate. The opinions were provided by qualified medical professionals and were predicated on a full reading of all available records. The examiners also provided a detailed rationale for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor the representative has challenged the adequacy of the examination or medical opinions obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2011). 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, 1131; 38 C.F.R. § 3.303(a). 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). Service connection may also 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). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a "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. Id. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. The term "chronic disease," whether as manifest during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In order to prevail on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1990). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1990); 38 C.F.R. § 3.303(a). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2011). When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board is required to render a finding with respect to the competency and credibility of the lay evidence of record. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competent, credible lay evidence could be, in and of itself, sufficient to establish an elemental fact necessary to support a finding of service connection. Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). As a fact finder, the Board is obligated to determine whether lay evidence is credible in and of itself. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, but it may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F. 3d 1331, 1336-1337 (Fed. Cir. 2006). Credibility is a factual determination going to the probative value of the evidence, to be made after the evidence has been admitted or deemed competent. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (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 facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr 21 Vet. App. at 303 (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). 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, 492 F. 3d at 1377. Also, a veteran as a layperson is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the layman is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F. 3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition; the person is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Service Connection for Osteoarthritis of the Left Knee The Veteran contends that service connection is warranted for osteoarthritis of the left knee. He has stated that, while he had informed the military at the time he entered service in 1975 that he had had knee problems before service, he injured his knee while stationed in Italy. Since that time, he has had numerous surgical procedures on his left knee. Review of STRs from the period of time when the Veteran has been found to be entitled to VA benefits (September 1977 to September 1981) shows that on examination in December 1976, prior to entry into active duty, and in September 1977, on examination for entry into service, the Veteran reported no history of having or having had a "trick" or locked knee. Clinical evaluation of the lower extremities was normal. In January 1978, the Veteran fell, landing on his left knee. His knee swelled, caused pain when he walked, and was tender to touch. In August 1979, the Veteran complained of recurring problems with pain of both knees. These usually subsided in approximately three to four days. The impression was chronic chondromalacia of both knees. The Veteran complained of having had knee pain since the age of twelve. Examination showed pressure over the patella with extension. The impression was chondromalacia. Examination for re-enlistment in May 1980 the Veteran reported no history of knee disability and clinical evaluation of the lower extremities was normal. Review of records from the period of active duty from which the Veteran has been banned from receiving compensation benefits ( from September 22, 1981, to March 1985) shows no complaint or manifestation of left knee disability. On physical examination in August 1984, clinical evaluation of the lower extremities was normal. Private treatment records show that the Veteran was treated for complaints of knee pain in the late 1990's. Records show that the Veteran sustained an injury of the left knee in a fall from a roof in 1996. MRI studies in 1998 and 1999 showed internal derangement of the left knee and a torn medial meniscus. Additional records show continued complaints of left knee disability and that the Veteran underwent a total left knee replacement in 2001. An examination was conducted by VA in May 2003. At that time, the Veteran stated that he had had pain in both knees since childhood and in boot camp his knees became more painful. He stated that, while in the Navy, he fell off a ladder and struck his left knee, which aggravated the already existing pain. Over the years, the pain became worse and, in May 2001, he underwent a total left knee replacement. The diagnosis was "degenerative joint disease, left knee, service connected." The examiner stated that, "if" the disability preexisted military service, it was aggravated by the extra stress based on ordinary military activities and the acute injury of the left knee. An addendum report to the May 2003 VA examination was conducted in June 2004. The examiner reviewed the Veteran's claims folder, including the opinion of the May 2003 examiner; the Veteran's lay statements regarding an injury of the left knee in a fall from a ladder during service; reports of private treatment beginning in 1996 after the Veteran reported that he had fallen from a roof; a January 1997 MRI study showing joint effusion, medial meniscal tear and chondral defects found over the femoral condyle; and evidence of degenerative arthritis of the left knee. The examiner summarized the medical history in the claims folder as showing that the Veteran had bilateral knee pain since age 12 due to chondromalacia patella, no evidence of a knee injury during service from 1977 to 1981, with current findings of degenerative arthritis of the left knee, ACL tear and posterior horn of the medial meniscus tear. The etiology of the left knee disability was noted to be chronic chondromalacia patellae, preexisted, aggravated from a fall from a roof in 1996 with ACL and posterior horn of the medial meniscal tears. The Veteran had undergone a repair of the ACL tear, but continued to have degenerative arthritis. The examiner rendered an opinion that the left knee arthritis was less likely than not related to service because chondromalacia patella had preexisted service and had been aggravated by a fall after service in 1996. An examination was conducted by VA in July 2006. At that time, it was reported that the Veteran had sustained a left knee injury in service in 1979 when he was treated with painkillers and crutches, with no following essential treatment. He fell and re-injured the knee in 1996, with the first surgery done on the knee in 1998, with additional surgeries performed in 1998 and 1999. The Veteran underwent a total knee replacement in May 2001. After this surgery he complained of constant pain in the left knee. The diagnoses were left knee injury "service connected in 1979," re-injured "nonservice-connected in 1996" with a medial meniscal tear, a ACL tear; status post arthroscopic surgery done in 1997, 1998, and 1999; and final surgery done for total knee replacement in 2001 for severe degenerative arthritis. An examination was conducted in March 2010 pursuant to the October 2008 remand of the Board. At that time, the Veteran gave a history of having injured his left knee in a fall down a ladder while onboard a Navy ship in 1977, with significant swelling, a period of crutches, and eventual return to full duty. Since that time he had had a total knee arthroplasty in 2001 and a revision in 2009, which reportedly went well. He continued to be hampered by pain, loss of motion, scarring, decreased activity and tenderness. The examiner was asked to render an opinion regarding whether the left knee condition is due to or a result of military service. The examiner responded that this could not be determined without resort to speculation. The rationale was that there was no way to know the extent of the original injury, which was likely a left knee sprain, which would not have led to arthritis; but could have been a meniscal tear, which could have led to arthritis. As there was no way to know the extent of the injury in service, any relationship with service would be speculative. In March 2011, the Board first referred the Veteran's claims folder to a physician of the VHA to ascertain whether the Veteran's left knee disability had pre-existed active duty, if so, whether it was aggravated beyond the natural progress of the disease during service, and if not, whether the current left knee disability was as likely as not related to the in-service injury in August 1979. The VHA physician responded in May 2011 that there was no undebatable evidence that the Veteran's left knee disability had existed prior to service. As such, there was no need to discuss whether there was an increase in the severity of a pre-existing left knee condition during service. Regarding whether any current chronic left knee disability was related to the in-service injury in August 1979, the VHA physician responded that the type of injury that had a strong correlation to the subsequent development in osteoarthritis that would lead to a knee replacement involved intra-articular fracture, significant chondral damage typically of the femoral condyle or tibial plateau, significant meniscal tear, and cruciate ligament tears. There was no compelling evidence in the medical records to suggest that any of these type of injuries occurred while the Veteran was in service. Rather, the Veteran's statements indicated that there was a worsening of his condition, which was presumed to be chondromalacia patellae, rather than an injury of a different part of the knee. The private treatment records indicated that the primary pathology that was addressed by the knee replacement was medial compartment arthritis, which the VHA physician could not find compelling evidence to link to an in-service injury. The strongest argument that could be made was that the fall in 1979 had resulted in a worsening of chondromalacia patella and that pain from this area of the knee contributed significantly to the decision to undergo a knee replacement. There was no documentation to support his argument so the standard of "as likely as not" was not met. Regarding whether it was as least as likely as not that the post-service injuries aggravated a chronic left knee disability that was incurred in or aggravated in service, the examiner concluded that the post-service injuries did aggravate any pre-existing knee condition that the Veteran might have had. The examiner noted that the 1997 thought 1999 private treatment records demonstrated two injuries. The first, a medial meniscus tear and femoral condyle cartilage injury was treated unsuccessfully with an arthroscopic surgery in 1997. The second, resulted in a torn ACL that was reconstructed. These three specific types of injuries are strongly associated with the subsequent development of osteoarthritis. Therefore, it was concluded that it was more likely than not that the two injuries described in the records of private post-service treatment were primarily responsible for the Veteran's osteoarthritis that eventually led to the knee replacement surgery. In September 2011, the Board sought another VHA opinion to clarify that rendered in May 2011. The Board requested that a VHA doctor review the evidence and render an opinion regarding whether it was at least as likely as not that any left knee disability that the Veteran had suffered any time since the Veteran submitted his claim of service connection in 2000 was related to the in-service injuries in 1978 and 1979 and, if so, whether it was at least as likely as not that the post-service left knee injuries had aggravated a chronic left knee disability that was incurred during service. In November 2011, the VHA doctor responded that it was unlikely that any post-service disability of the left knee had resulted from the in-service injury noted in 1978 or the subsequent visit for knee pain one year later. The rationale was that the only injury noted in the STRs was the 1978 injury when the Veteran reported having tripped over a wire rope landing on his hands and left knee. At that time, the Veteran was noted to have a swollen knee that was tender to the touch and an Ace wrap and aspirin were used as treatment. 18 to 20 months later, the Veteran was seen for bilateral knee pain with no report of a precipitating knee injury. On examination by a Navy corpsman, the Veteran reported that he had intermittent, recurrent pain that usually resolved within three to four days. A physician subsequently examined the Veteran's knees and found no ligamentous instability, no indication of a meniscal tear, and no decrease in range of motion. The diagnosis at that time was chondromalacia patellae, which is also commonly known as patellofemoral dysfunction or anterior compartment pain syndrome. The VHA doctor went on to state that the injury from the fall in 1978 appeared to have been a straightforward contusion that resolved, as evidenced by the period of time between the initial diagnosis and any subsequent visits for knee pain. Examination and history supported the diagnosis of chondromalacia patellae, which was not considered by the doctor to generally result in later osteoarthritis. It was considered that it was far more likely that the fall from the roof that the Veteran reported to his private physicians as having occurred in 1996 resulted in the damage to the knee that ultimately progressed to the current state of degenerative joint disease. The evaluations showed a meniscal tear, cruciate ligament disruption, and a full-thickness chondrolysis of the medial femoral condyle. These diagnoses were well known to result in progressive degeneration of the knee. Therefore, it was considered unlikely that the Veteran's current degenerative disease of the knee was the result of the injury sustained in service. It was more likely that this degenerative disease was the result of the injury sustained in the fall from the roof in 1996. Regarding the second question put the VHA doctor, whether it was at least as likely as not that the post-service injuries aggravated a chronic knee disability that was incurred during service, the examiner stated that there was no documented chronic knee disability in service. There was evidence of an intermittent recurrent pain that was not supported by physical findings and only noted twice in a four-year period. There was a 15-year period before there was any mention of knee problems occurring an any of the Veteran's subsequent medical records, and the Veteran had given a personal history that those knee problems had begun after a fall in 1996. As such, the examiner stated that there was no disability of the left knee that was incurred during military service and the current condition, and the conditions leading up to the current state, all stemmed from post-service events. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). 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 Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140, 146 (1993); Guerrieri, 4 Vet. App. at 470-71. While the Board may not ignore a medical opinion, it is certainly free to discount the relevance of a physician's statement. See Sanden v. Derwinski, 2 Vet. App. 97 (1992). In this case, there are several medical opinions regarding whether the Veteran's current left knee disability could be related to the injury sustained and the complaints of knee pain that he had during his period of active duty. There are conflicting opinions regarding whether the Veteran's left knee disability pre-existed active duty. The Veteran is presumed to have been in sound condition when examined, accepted, and enrolled for service except as to defects, infirmities, or disorders noted at the time of examination, acceptance, enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the "correct standard for rebutting the presumption of soundness under section 1111 requires the government to show by clear and unmistakable evidence that (1) the veteran's disability existed prior to service and (2) that the pre-existing disability was not aggravated during service." The Federal Circuit noted that lack of aggravation could be shown by establishing there was no increase in disability or that any increase in disability was due to the natural progress of the pre-existing condition. See Wagner v. Principi, 370 F.3d 1089, 1096-1097 (Fed. Cir. 2004). A left knee disability was not noted when the Veteran was examined in September 1977, on entry into service. The Veteran reported no history of having or having had a "trick" or locked knee, and clinical evaluation of the lower extremities was normal. Consequently, the presumption of soundness attached, and the analysis proceeds to the question of whether that presumption was rebutted. The government must show by clear and unmistakable evidence that the Veteran's left knee disability was both preexisting and not aggravated by service. The record contains conflicting evidence regarding whether a left knee disorder preexisted service. The only evidence of pre-existence consists of the Veteran's statements that he had knee pain since age 12, but there is no actual evidence of preexistence and, as the VHA physician stated in May 2011, there is certainly no undebatable evidence of a pre-existing disability. While the 2003 VA examiner indicated that chondromalacia patella had preexisted service, given the findings of the 2011 VHA opinion provider, the record does not contain clear and unmistakable evidence that a left knee disorder preexisted service. For these reasons, the presumption of soundness has not been rebutted. Consequently, it is not necessary for the Board to consider the second element with respect to rebutting the presumption of soundness. The Board will continue with an analysis of whether a left knee disorder was incurred as a result of service. The issue is whether the Veteran had a chronic disability resulting from an in-service injury and whether that disability was etiologically related to the current disability of his left knee. In November 2011, the VHA doctor answered these questions in the negative. The Board finds this opinion to be the most persuasive evidence of record on these points, particularly in light of the thorough rationale. The VHA doctor explained that the in-service injury appeared to have been a straightforward contusion that resolved, as evidenced by the period of time between the initial diagnosis and any subsequent visits for knee pain. Further, the physician opined that the chondromalacia patella noted in service was not considered by the doctor to generally result in later osteoarthritis. Further, the physician's opinion is highly probative as he explained a far more likely etiology of the Veteran's arthritis: the post-service fall from the roof. The examiner also explained that the fact that the Veteran had no complaints of left knee disability in the 15 years between the end of his recognized period of service in 1981 and the 1996 injury sustained in a fall from a roof did not support the claim. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Given the thoroughness of the opinion provider's rationale, the Board accords great probative weight to that opinion. The absence of clinical treatment records for approximately 15 years after active duty can be considered as one element of probative evidence against a service relationship. See Mense v. Derwinski, 1 Vet. App. 354 (1991). On the other hand, the March 2010 VA examiner's opinion has little or no probative value because the examiner stated he could not provide an opinion without resort to speculation. Likewise, as the March 2011 VHA opinion has little or no probative value as the opinion was based on an inadequate review of the file. The opinion stated that records from the "1979 injury were not made available for review," indicating that the relevant STRs from 1978 and 1979 were not considered in the formulation of the opinion. Service connection for left knee arthritis on a presumptive basis is not warranted as arthritis was shown within one year of the Veteran's period of recognized service. 38 C.F.R. §§ 3.307, 3.309. The November 2011 VHA opinion provider stated that arthritis far more likely developed many years after service: after the 1996 fall. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim of service connection for a left knee disability, 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. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Earlier Effective Date for Hypertension Review of the record shows that service connection for hypertension was awarded by the RO in an August 2004 rating decision. The award was based on a confirmed diagnosis of hypertension made during a VA examination report dated on May 30, 2003. The RO assigned an effective date of May 30, 2003, as the VA examination report of that date was considered to have constituted an informal claim for the benefit. The Veteran disagreed with the effective date, asserting that he had submitted a claim for compensation benefits in 1985 and that service connection should have been established as of that date. The JMR that vacated the October 2008 decision that found no basis to award an effective date prior to May 30, 2004 noted a "December 2000" claim of service connection for "a heart condition" and noted a diagnosis summary from private treatment in October 1999 when the Veteran was diagnosed with hypertension. The Board was ordered to take into consideration whether the Veteran had submitted an informal claim for hypertension as of December 2000. Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a), (b); 38 C.F.R. § 3.400,(a), (b). The effective date for the grant of service connection is the day following separation from active service or the date entitlement arose, if the claim is received within one year after separation from service; otherwise, it is the date of receipt of claim, or the date entitlement arose, whichever is later. Id. Any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next of friend of a claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. 38 C.F.R. § 3.155 (a). Once a formal claim for pension or compensation has been allowed or a formal claim for compensation disallowed for the reason that the service-connected disability is not compensable in degree or a claim for pension denied for the reason the disability was not permanently and totally disabling, receipt of one of the following may be accepted as an informal claim for increased benefits or an informal claim to reopen: The date of outpatient or hospital examination or date of admission to a VA hospital or uniformed services hospital. The date of receipt of evidence from a private physician when evidence furnished by or on behalf of the claimant is within the competence of the physician. 38 C.F.R. § 3.157(b). Review of the record shows that the Veteran's initial claim for compensation benefits, in 1985, included claims of service connection for pneumonia, a psychiatric disorder, and alcoholism. Subsequent correspondence that year added claims of service connection for sickle cell trait, hearing loss, a skin disorder and "right lung damage." There was no indication in the initial claims for compensation benefits for service connection of a heart disorder, hypertension or hypertensive cardiovascular disease. The Board has reviewed the entire record at length and has been unable to locate the claim of service connection for a heart condition dated in December 2000 that was referenced in the JMR. A search of documents presented to the Court produced the document referenced in the JMR (R. at 1038). This document is not a claim, but is an April 2003 RO rating decision notification letter. The April 2003 notification letter reported that service connection was denied for diabetes mellitus and a heart condition based on a "claim for service-connected compensation received on December 8, 2000." The only correspondence dated and received from the Veteran by VA in December 2000 referred to disabilities including the Veteran's knee disability and sickle cell trait, but not to a heart condition. Therefore, the Board must conclude that the JMR reference is a typographical error. There is a written statement dated November 8, 2000, (and date stamped as received by VA on November 9, 2000) from a congressional office to the VA which includes as an attachment a 2-page written statement from the Veteran dated October 28, 2000, wherein the only reference to his heart is the statement "[a]nd other than having bad knees a bad heart now and diabetes and bipolar manace [sic] depressant disorder I'm just fine." In an earlier, July 2000 statement, the Veteran referred to claims involving alcoholism and submitted records from a private hospital, dated from 1998 to 1999. These records included a report of an October 1999 private hospitalization where the Veteran was initially evaluated for chest pain with a principal diagnosis of chest pain-noncardiac, and hypertension. The Veteran was hospitalized and underwent a cardiac catheterization after which he was found to be delirious and was taken for a psychiatric consultation. The pertinent discharge diagnosis was hypotension. The Board finds that the preliminary diagnosis of hypertension on the emergency room treatment record dated in October 1999 was not supported by follow-up examination in the hospital when the discharge diagnosis of hypotension was made. Moreover, the July 2000 statement cannot be considered a claim of service connection for either heart disease or hypertension, as the Veteran did not mention these disabilities in his correspondence. See Brannon v. West, 12 Vet. App. 32, 35 (1998) (The mere receipt of medical records cannot be construed as an informal claim for the benefit.). In an October 11, 2000 statement, received by VA on October 13, 2000, the Veteran repeated contentions regarding the injury of his knees, stated that he was a diabetic and that he had a "mental problem." He also stated that "since the last time I wrote to you I have found out from being in the hospital that I have a heart problem and here is the proof." Medical records associated with this statement included a September 2000 examination report that showed a past history of cardiomegaly in 2000 and a reference to Class I organic heart disease, without symptoms. The Veteran was placed on the medication Digoxin. There was no diagnosis of hypertension made. The record does not include any communication or record of any communication from the Veteran or a representative received prior to October 13, 2000, that may reasonably be construed as an indication he was seeking service connection for hypertension. An April 2003 rating decision denied service connection for a heart condition. The Veteran was notified of this action and of his appellate rights, including the need to evidence disagreement with the rating decision within one year, by letter dated April 4, 2003. The record contains an April 10, 2003 statement from the Veteran which stated: "it's amazing page three says admitted for heart condition so that letter I received from you about my 'heart condition' and that it was denied 'I want to appeal' that decision so now its on the record I want it Appealed!" Thereafter, an August 23, 2003 statement of the case continued to deny heart disease; however, an August 23, 2003 rating decision awarded service connection for hypertension effective May 30, 2003, the date of a VA examination which diagnosed hypertension. The August 2003 rating decision noted that it accepted the Veteran's May 2003 VA examination report as an informal claim. However, given the VA's obligation to give a "sympathetic reading" to a veteran's filings, the Board finds that the October 13, 2000, filing for a "heart condition" included an informal or inferred claim for hypertension. See Schroeder v. West, 212 F.3d 1265, 1271 (Fed. Cir. 2000). At the time of the May 2003 VA examination a history of hypertension and cardiomyopathy was reported. Examination showed blood pressure readings of 130/90, 130/90, and 130/100. The pertinent diagnoses were history of cardiomyopathy and hypertension. The Veteran did not submit a claim of service connection for hypertension in 1985. He did submit a claim for service connection for a heart condition on October 13, 2000. As he continuously prosecuted the heart condition claim until service connection for hypertension was awarded, the Board finds that October 13, 2000, is the date of claim in this case. As noted above, the effective date of an evaluation and award of compensation based on an original claim, as here, will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a), (b); 38 C.F.R. § 3.400,(a), (b). The August 2003 grant of service connection was awarded based in part on service treatment records showing that the Veteran developed hypertension while in active service. STRs showed that the Veteran had episodes of elevated blood pressure in service. Accordingly, the date entitlement arose was prior to the October 13, 2000, date of claim. As the October 13, 2000, date is later than the date entitlement arose, the effective date of service connection for hypertension is October 13, 2000. ORDER Service connection for osteoarthritis of the left knee is denied. An effective date of October 13, 2000, for an award of service connection for hypertension is granted. REMAND The Veteran has also claimed service connection for a psychiatric disability, specifically bipolar disorder. As pointed out in the October 2008 remand of the Board, STRs show that he was treated for depression during his recognized period of service, that he underwent a psychiatric evaluation in 1984, and was treated at a VA facility for episodic panic attacks from January to April 1985. At that time a cyclothymic personality was included among the diagnoses. In September 1999 he was diagnosed at a private facility with mixed-type bipolar disorder. The October 2008 remand requested that a psychiatric evaluation be undertaken by VA to ascertain whether any currently diagnosed psychiatric disability was associated with the episode of depression demonstrated in the STRs. This was arranged and the Veteran was seen by a VA psychiatrist in April 2010, but at that time, the Veteran was described as being very hostile and uncooperative. Because of this, the examiner was unable to render the nexus opinion requested by the Board. Service connection remained denied and the case was returned to the Board following the issuance of an April 2010 Supplemental Statement of the Case. The Board notes that at no time during the appeal has the Veteran been notified of the need to cooperate with VA examination requests and the consequences of noncooperation. When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination was scheduled in conjunction with any other original claim, a reopened claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied. 38 C.F.R. § 3.655 (2012). As such, and to afford the Veteran every consideration, the Board finds that an additional attempt should be made for the Veteran to undergo a psychiatric examination. Accordingly, the issue of service connection for an acquired psychiatric disorder is REMANDED for the following action: 1. The RO/AMC should arrange for the Veteran to undergo a psychiatric examination to ascertain the current nature and extent of any psychiatric disorder diagnosed since this claim was filed in 2000, to include bipolar disorder. The examiner should be requested to render an opinion regarding whether it is at least as likely as not (probability 50 percent or more) that any such psychiatric disorder, including bipolar disorder, had its onset during the Veteran's period of honorable service (September 21, 1977, to September 21, 1981). The claims folders should be made available for review in connection with this examination. The examiner should provide complete rationale for all conclusions reached. 2. Thereafter, the RO/AMC should readjudicate the remaining issue on appeal. If the determination remains unfavorable to the Veteran, he and his representative should be provided with a supplemental statement of the case (SSOC) that addresses all relevant actions taken on the claim for benefits. The Veteran should be given an opportunity to respond to the SSOC prior to returning the case to the Board for further review. 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). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2012). 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). ______________________________________________ M. C. GRAHAM Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs