Citation Nr: 1318823 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 96-24 051 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a low back disorder, claimed as secondary to the service-connected left knee disability. 2. Entitlement to service connection for a left hip disorder, claimed as secondary to the service-connected left knee disability. 3. Entitlement to service connection for a right knee disorder, claimed as secondary to the service-connected left knee disability. REPRESENTATION Appellant represented by: Sean A. Ravin, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD G. Jackson, Counsel INTRODUCTION The Veteran had active service from January 1970 to January 1974. This case initially came before the Board of Veterans' Appeals (Board) on appeal from a September 1995 rating decision of the RO. The Veteran testified at a hearing held at the RO before a Hearing Officer in September 1996 and later at a hearing held before the undersigned Veterans Law Judge in Washington, DC in December 1998. The Board initially remanded the case to the RO in May 1999 for additional development of the record. The Board denied the claims in a decision promulgated in September 2005. The Veteran thereupon appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In August 2006, the Court issued an Order granting a Joint Motion for Remand (JMR) by the parties, vacating the decision and remanding the matters to Board for further action. In April 2007, the Board remanded the case to the RO via the Appeals Management Center (AMC) in Washington, DC for actions in compliance with the JMR. In a May 2008 decision, the Board once again denied the Veteran's claims. The Veteran appealed the decision, and the Court issued a March 2009 Order granting another parties' Joint Motion, vacating the May 2008 decision in part and remanding the issues of service connection for low back condition, and right knee and left hip disorders for compliance with the terms of the JMR. The Board then remanded the claims to the RO in May 2009 for actions in compliance with the JMR. In a March 2010 decision, the Board once again denied the Veteran's claims. The Veteran appealed the decision, and the Court issued an Order in October 2010 that granted the parties' Joint Motion, vacating the decision and remanding the matters for compliance with the terms of the JMR. The Board then remanded the case to the RO for actions in compliance with the Court's Order in March 2011, February 2012 and May 2012. That development having been completed, the case has since been returned to the Board for the purpose of appellate review. Finally, the Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDING OF FACT The most probative medical opinion of record establishes that the Veteran's claimed low back, left hip and right knee disorders were not caused or aggravated by his service-connected left knee disability. CONCLUSIONS OF LAW 1. The Veteran does not have a low back disability that is proximately due to or the result of the service-connected left knee disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2011). 2. The Veteran does not have a left hip disability that is proximately due to or the result of the service-connected left knee disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2011). 3. The Veteran does not have a right knee disability that is proximately due to or the result of the service-connected left knee disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2011). REASONS AND BASES FOR FINDING AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2011) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2011). The notice requirements of VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2011). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any defects in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In this case, in a June 2007 letter issued subsequent to the decision on appeal, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claims for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letter provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. After issuance of the June 2007 letter, and an opportunity for the Veteran to respond, the February 2008 Supplemental Statement of the Case (SSOC) reflects readjudication of the claims (most recently, a November 2012 SSOC readjudicates the claims). Hence, the Veteran is not shown to be prejudiced by the timing of this notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA and private treatment records and VA examination reports. The Board is aware that this appeal was, most recently, remanded by the Board in May 2012. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a Court or Board remand confers upon the appellant the right to compliance with that order). That remand requested that the RO obtain an adequate VA medical opinion regarding the etiology of the Veteran's low back, left hip and right knee disorders. Specifically, a board of orthopedists, which did not include the VA physician who performed the examination in May 2003, was to address whether the Veteran's claimed low back, left hip and right knee disorders were caused or permanently worsened by the service-connected left knee disability. This development was completed in the October 2012 VA examination report when a board of orthopedic surgeons, comprised of Drs. L., M. and C. examined the Veteran to ascertain the nature and likely etiology of the Veteran's claimed low back, left hip and right knee disorders. Accordingly, the Board finds that there has been substantial compliance with its previous remand and it may proceed to adjudication of this appeal. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Boards remand order). The VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by providing evidence and argument and presenting for VA examinations. Thus, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any defect in the sequence of events or content of the notices is not shown to have any material effect on the case or to cause injury to the Veteran. Therefore, any such defect is harmless and does not prohibit consideration of this matter on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). In addition, during the hearings the RO hearing officer and VLJ clarified the issues, determined that there might be additional evidence and addressed the Veteran's manifestations. Such actions supplemented VCAA and complied with 38 C.F.R. § 3.103 (even if not applicable). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Laws and Regulations Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). 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). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The provisions of 38 C.F.R. § 3.310 were amended, effective on October 10, 2006; however, the new provisions 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. 71 Fed. Reg. 52744 -47 (Sept. 7, 2006). Although the stated intent of the change was merely to implement the requirements of Allen v. Brown, 7 Vet. App. 439 (1995), the new provisions amount to substantive changes to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the claimant because it does not require the establishment of a baseline before an award of service connection may be made. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Factual Background The Board initially acknowledges that there are of record VA examination reports dated in June 1995, November 1999, May 2003 and November 2007. The first JMR, as incorporated by the Court's Order, held that the May 2003 opinion regarding the etiology of the claimed disorders might have been tainted by improper correspondence by the RO; accordingly, this opinion as to the question of etiology will not be addressed in this case. Thereafter, in response to the Board's remand and in compliance with the Court's August 2006 Order, the Veteran had another VA examination in November 2007. The examiner was the same physician who had examined the Veteran in June 1995 and November 1999. The second Joint Motion for Remand, as incorporated by the Court's order, held that the November 2007 opinion contradicted the November 1999 opinion and did not offer a clear explanation for the opinion. Additionally, the June 1995 opinion was noted to be couched in speculative terms and was therefore of limited probative value. See Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (medical opinions which are speculative, general or inconclusive in nature cannot support a claim). The parties also agreed that a remand was necessary as the terms of the previous Joint Motion for Remand had not been fully addressed by the VA examination in November 2007. Accordingly, to the extent indicated, the June 1995, November 1999, May 2003 and November 2007 VA opinions are deemed to be of very limited probative value for the purpose of deciding the appeal. In August 2009, the Veteran was examined by a VA nurse practitioner (NP) who concluded that the Veteran's spine, hip, and right knee problems were not caused by his service-connected left knee disability; specifically, the NP found that no functional impairment of the spine, left hip or right knee existed and that the degenerative changes were more likely the result of aging rather than biomechanical alteration resulting from the service-connected left knee disability. In September 2009, an examination request was issued so that a different physician could co-sign the examination report. In October 2009, a different physician co-signed the report, and an addendum was issued that noted that he had reviewed the claims file and concurred with the report. In February 2010, the Veteran's attorney asserted that the Board had not complied with its previous Remand because the Veteran had not been afforded an independent VA examination and opinion. In March 2010, the Board issued a decision denying the claims. The parties found that the Board primarily relied on the August 2009 VA examiner's opinion, although the October 2009 addendum was of record. In an October 2010 Joint Motion for Remand, the parties, citing Stegall v. West, 11 Vet.App. 268, 271 (1998), found that the Board had provided an inadequate statement of reasons or bases in its decision by not addressing whether VA had complied with the terms of prior Remands. Specifically, the parties noted that the two JMRs required that "the Board and the RO should request a medical opinion from a board of VA orthopedists, which should not include [an identified earlier examiner] or the May 2003 examiner" if a new examination was needed. This identified earlier examiner conducted the November 2007 examination and cosigned the nurse practitioner's initial opinion in August 2009. Although the opinion was reissued in September 2009 and consigned by a different physician in October 2009, the Board had not addressed whether a nurse practitioner's opinion substantially complied with the remand request for an opinion from "a board of VA orthopedists." The parties concluded that the appeal must be remanded and that VA must "request a medical opinion from a board of VA orthopedists, which should not include [the previously identified examiner] or the May 2003 VA examiner" in order to comply with the JMRs. It was also noted that to the extent that VA was unable to obtain an opinion from a board of VA orthopedists, the parties agreed that the Board must explain how the efforts of VA substantially complied with the directive of the October 2010 JMR, August 2006 JMR, and March 2009 JMR. In March 2011, the Board remanded the issues on appeal for compliance with the Joint Motion instructions, and the RO was specifically directed to request a medical opinion from an appropriate board of VA orthopedists in order to determine the nature and likely etiology of the claimed low back, left hip and right knee disorders. The RO afforded the Veteran a VA examination in August 2011 and an addendum medical opinion was obtained in December 2011 as to the likely etiology of the claimed disorders. However, the VA examination was conducted by an orthopedic physician, not a board of VA orthopedists. An explanation from the RO was not provided as to why the Veteran was not examined by a board of orthopedists or whether this request could be accomplished or was feasible. There was no discussion from the RO as to the efforts taken to substantially comply with the March 2011 remand. Accordingly, the August 2009, October 2009, August 2011 and December 2011 VA opinions of etiology will not be considered. Analysis The Board will discuss the claimed low back, left hip and right knee disorders together, since the symptomatology is intertwined with a common history of chronic pain syndrome; also, VA and non-VA examination reports tend to address multiple joints. The Board has only considered the Veteran's claim on a secondary basis. The Joint Motions did not identify any deficiency as to the scope of the Board's analysis. There is one medical opinion in favor of the claim. The file contains January and March 1996 letters from a private physician stating that he had been treating the Veteran for chronic pain for the past year. He opined that the Veteran's current low back, left hip and right knee conditions all related back to the initial service-connected left knee problem. The Veteran's right knee problem began with offloading from the left knee, which precipitated degenerative changes and meniscal tear. It also caused progressive somatic dysfunction involving the sacroiliac joints and piriformis myospasms. In this opinion, it was noted that had it not been for the left knee problems the Veteran would be having no problems whatsoever in the low back, right knee or hips. The private physician submitted another letter to VA in November 1998 asserting that he was still treating the Veteran for chronic pain symptomatology. He stated that the Veteran's left knee derangement continued to be the major causative factor in his current chronic pain symptomatology including the low back pain and bilateral lower extremity symptomatology. The physician opined that the Veteran had suffered significant consequences due to the severity and chronicity of the previous left knee instability including right knee instability and low back pain with progressive degenerative disc disease. The Veteran's continued pain symptomatology was noted to be all secondary to the previous left knee instability. In his professional opinion, the Veteran's multi-level somatic dysfunction was of a permanent and progressive nature and was a direct result of his compensatory left knee instability. In contrast to the private physician's opinions is that of the October 2012 board of VA orthopedic surgeons, comprised of Drs. L., M. and C. The board of orthopedic surgeons identified and discussed the Veteran's medical history. The Veteran was noted to have reported that he noticed his back pain in the late 1980's; in the early 1990's, he said that his back pain started acting up. He reported being discharged from the Naval Reserve due to the pain in his back (and knees). The Veteran also complained that the pain got worse and moved through the back into the hip and SI joint. He described the pain as a constant pain. He complained of no specific injury, nor did he provide a specific date of the onset of the pain. Reportedly, sitting or standing too long and any kind of work exacerbated his back pain. Medication and a back brace helped to alleviate the pain. The Veteran reported that his left hip began hurting when his back was hurting. The pain was described as intermittent. Physical therapy helped the back and hip pain, but driving to physical therapy was "a burden." The Veteran had no complaints of radiating pain from the back or hip. His description of the pain implied that, while it was worse than it was in the 1980's, it was not significantly worse now than it was a year or five years ago. Regarding the right knee, the Veteran complained that his knee had locked up intermittently until approximately 1985 when it locked up permanently. He underwent partial medial meniscectomy and, after surgery, did well for about four or five years. Then, in the early 1990's, the Veteran started having severe pain and arthritis. Ocassionally, he would experience swelling. His knee would give out on him. Squatting, kneeling, walking on uneven ground and stairs caused pain. Franklin knee pads seemed to offer some relief. On examination, the diagnoses were those of degenerative disc disease of the lumbar spine to L5-S1, left SI joint pain and right knee medial meniscus tear. After careful consideration of the Veteran's claim file (in its entirety), taking a history from the Veteran and performing detailed physical examinations of the back, left hip and right knee, the board of orthopedic surgeons concluded that the service-connected left knee disability did not cause or permanently worsen the Veteran's back, left hip or right knee disorders. Regarding the right knee, the board of orthopedic surgeons explained that the Veteran's gait was not biomechanically altered as evidenced by essentially even wear on his shoes. There was no bowing or clinically obvious shortening of the left leg that would have increased the strain on the right knee. The tenderness of the right knee, painful McMurray's examination and radiographic findings were all consistent with the natural progression of osteoarthritis. The board of orthopedic surgeons also noted that the Veteran could not identify a cause as the origin of his back pain or remember a specific inciting episode. A review of the claims file review showed that many exacerbations of the back pain were caused by specific twisting motions that occurred in proximity to a medical visit. The lack of a biomechanical altered gait also supported the conclusion that the back pain was not exacerbated by the service-connected left knee disability. The board of orthopedic surgeons found that the minimal arthritic changes and the disc desiccation were both conditions associated with aging. Regarding the left hip disorder, the board of orthopedic surgeons noted that the degenerative changes seen on x-ray study were bilateral and minimal. There was no loss of joint space. The pain the Veteran described in his left hip joint was exacerbated by hip flexion which also exacerbated his low back pain. Twisting of the service-connected left knee disability did not exacerbate the left hip pain. Thus, the board of orthopedic surgeons concluded, taking into consideration the subjective and objective data and based on a review of the claims file, that the Veteran's low back, left hip and right knee disorders were not caused by or permanently worsened as a consequence of his service-connected left knee disability. The Board is obligated under 38 U.S.C. § 7104(d) to analyze the credibility and probative value of all evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide reasons for its rejection of any material evidence favorable to the veteran. See, e.g., Eddy v. Brown, 9 Vet. App. 52 (1996). The Board has the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). However, the Court has held that the Board may not reject medical opinions based on its own medical judgment. See Obert v. Brown, 5 Vet. App. 30 (1993). The Court has stated, in pertinent part, that the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Board has carefully evaluated the conflicting evidence and places greater weight on the opinion of the October 2012 VA board of orthopedic surgeons, comprised of Dr. L., M. and C. than it did on the January and March 1996 and November 1998 opinions presented by the private physician. The Board initially notes that it is a matter of public record that the private physician pleaded guilty in September 2005 to felony misconduct beginning in 1998 and apparently surrendered his medical license and his Drug Enforcement Agency license. Given the pattern of misconduct, the Board finds that physician's statements inherently lack credibility and, to the extent they are not supported by other competent evidence or medical opinion, must be seriously discounted in this case. Crucially, the private physician's opinions are not consistent with the totality of the record regarding the severity of the Veteran's symptoms. He asserted that the Veteran had exhibited severe instability of the left knee, resulting in chronic pain and severe and debilitating degenerative disorders of the other joints. However, none of the other medical examination reports of record, found any instability of the left knee. Moreover, the contemporary VA treatment notes have recorded for clinical purposes that the Veteran was a chronic pain patient exhibiting "drug-seeking behavior," i.e. overstating the severity of symptoms in order to obtain prescription medications (see VA neurology consultation in May 1992 and VA neurology consult in September 1994), and in March 2003, VA refused to provide the Veteran with a refill of narcotic pain medications due to evidence of concurrent abuse of amphetamines. In the evaluation of evidence, VA adjudicators may properly consider internal inconsistence, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 510-11 (1995), aff'd 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). Given that the totality of the evidence shows no instability of the left knee, and to the extent that the low back, right knee and left hip disorders are shown to be much less severe than represented by the private physician., the Board finds that the private physician's opinion was based on a factual premise that was not consistent with the medical evidence of record. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion."). Thus, in this case, the Board accords greater probative weight to the comments and opinion provided by the October 2012 VA board of orthopedic surgeons as they were based on a thorough review of the medical records (including conflicting medical evidence), taking the Veteran's history and performing examination. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)); see also Winsett v. West, 11 Vet. App. 420 at 424-25 (it is not error for the Board to value one medical opinion over another, as long as a rational basis for doing so is given) and Guerrieri, supra. The only other evidence of record supporting the Veteran's claims are his various general lay assertions. In this case, the Veteran is competent to state that his service-connected left knee disability has caused or contributed to his low back, left hip and right knee pain (the Board notes that he has consistently made this assertion). See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). Here, the Board finds his assertions are not found to be of limited credibility and probative weight because the record shows that the Veteran tends to exaggerate to severity of his physical manifestations. Moreover, in this case, the Board finds the opinion of the VA board of orthopedic surgeons in the October 2012 report VA examination to be most probative. The VA board of orthopedic surgeons are medical professionals who has reviewed the claims file, considered the reported history and performed physical examination. The board of orthopedic surgeons used their expertise in reviewing the facts of this case and determined that the claimed low back, left hip and right knee disorders were unrelated to the Veteran's service-connected left knee disability. It is clear that the board of orthopedic surgeons fully understood the basis for the Veteran's claims yet still determined, after reviewing the facts of the case, that the current low back, left hip and right knee disorders were related to causes other than the Veteran's service-connected left knee disability. Moreover, the Veteran has not suggested that this examination was performed in an insufficient manner. For the foregoing reasons, the Board finds that the claims of service connection for low back, left hip and right knee disorders, as secondary to the service-connected left knee disability must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. As the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for a low back disorder, claimed as secondary to the service-connected left knee disability is denied. Service connection for a left hip disorder, claimed as secondary to the service-connected left knee disability is denied. Service connection for a right knee disorder, claimed as secondary to the service-connected left knee disability is denied. ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs