Citation Nr: 1319192 Decision Date: 06/12/13 Archive Date: 06/21/13 DOCKET NO. 09-08 690 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for status post lumbar laminectomy, L5-S1, to include arthritis, claimed as secondary to a service-connected left knee disability. 2. Entitlement to service connection for a neck disability, characterized as arthritis, claimed as secondary to a service-connected left knee disability. 3. Entitlement to service connection for a bilateral shoulder disability, claimed as secondary to a service-connected left knee disability. 4. Entitlement to service connection for an acquired psychiatric disability, other than post-traumatic stress disorder (PTSD), claimed as secondary to a service-connected left knee disability. REPRESENTATION Appellant represented by: Illinois Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from January 1954 to January 1956. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a Regional Office (RO) decision issued in July 2007 by the Department of Veterans Affairs (VA) RO in Chicago, Illinois. In February 2012, the Veteran testified before the undersigned Veterans Law Judge via videoconference. A copy of the hearing transcript is of record and has been reviewed. The Veteran clarified that the issues remaining on appeal are claimed on a secondary basis. Thereafter, the Board remanded this case in April 2012. In a February 2013 decision, the Board reopened the claim of service connection for left knee disability, status post total knee arthroplasty, and remanded the matters of service connection for left knee disability, status post total knee arthroplasty, as well as service connection for status post patellectomy of the right knee with internal derangement, status post lumbar laminectomy of L5-S1 to include arthritis, a neck disability characterized as arthritis, a bilateral shoulder disability, and an acquired psychiatric disability, other than PTSD, all claimed as secondary to status post total knee arthroplasty, left knee. In an April 2013 rating decision, service connection was granted for left and right knee disorders. The remaining issues were recertified to the Board. 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). FINDINGS OF FACT 1. A low back disability is not etiologically related to a service-connected left knee disability. 2. A neck disability is not etiologically related to a service-connected left knee disability. 3. A bilateral shoulder disability is not etiologically related to a service-connected left knee disability. 4. The Veteran does not have a current diagnosis of a psychiatric disability which is etiologically related to a service-connected left knee disability. CONCLUSIONS OF LAW 1. A low back disability is not proximately due to, the result of, or aggravated by a service-connected left knee disability. 38 U.S.C.A. § 1101 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.310(a) (2006). 2. A neck disability is not proximately due to, the result of, or aggravated by a service-connected left knee disability. 38 U.S.C.A. § 1101 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.310(a) (2006). 3. A bilateral shoulder disability is not proximately due to, the result of, or aggravated by a service-connected left knee disability. 38 U.S.C.A. § 1101 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.310(a) (2006). 4. A psychiatric disability is not proximately due to, the result of, or aggravated by a service-connected left knee disability. 38 U.S.C.A. § 1101 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.310(a) (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim, including apprising him or her of the information and evidence he or she is responsible for providing versus the information and evidence VA will obtain for him or her. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). So this notice must include information that a "downstream" disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, this notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary notice and then readjudicating the claim - including in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has made clear that VCAA notice errors are not presumptively prejudicial, rather, must be determined on a case-by-case basis, and that, as the pleading party attacking the agency's decision, the Veteran, not VA, bears this burden of proof of establishing there is a VCAA notice error and, moreover, above and beyond this, that the error is unduly prejudicial, meaning outcome determinative of the claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of the claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir., 2004). VCAA letters were sent in June 2006, October 2006, and May 2012. The letters, especially in combination, indicated the type of evidence and information needed to substantiate the claim and apprised the Veteran of the Veteran's and VA's respective responsibilities in obtaining this supporting evidence. The letters also notified the Veteran that a "downstream" disability rating and an effective date for the award of benefits would be assigned if service connection was granted, in compliance with Dingess. The Veteran has been afforded a hearing before a Veterans Law Judge (VLJ) in which he presented oral argument in support of his claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims ("the Court") held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issue and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ did not specifically note the bases of the prior determination or the elements that were lacking to substantiate the claims. The VLJ asked specific questions, however, directed at identifying whether the Veteran had symptoms pertaining to his claimed disabilities and their potential relationship to his left knee disability. The VLJ sought to identify any pertinent evidence not currently associated with the claims and the Veteran also volunteered his treatment history. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Regarding the duty to assist, VA also satisfied this obligation in terms of obtaining all potentially relevant evidence concerning these claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records (STRs), VA medical treatment records, and identified private medical records were obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Although records from the Social Security Administration were requested, the records had been destroyed, as documented in a July 2012 Formal Finding of Unavailability of these records. There is no indication that any additional evidence, relevant to these claims, is available and not part of the claims file. The Veteran also was provided VA compensation examinations, including for medical nexus opinions concerning the etiology of the claimed disorders and their potential relationship with his left knee disability, as the Board directed when remanding these claims. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The medical nexus opinions obtained are responsive to the determinative issue of causation, so additional examinations and opinions are not needed. 38 C.F.R. § 4.2. See also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). And see Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (VA's duty to assist includes providing an adequate examination when such an examination is indicated). The examinations of record are adequate to address all pertinent concerns, as the claims file was reviewed for the relevant medical and other history, the Veteran examined, the findings reported in sufficient detail, and there was discussion of the underlying medical rationale, which is where most of the probative value of an opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The VA examination reports are thorough and supported by the record. The records taken as a whole satisfy 38 C.F.R. § 3.326. Furthermore, in obtaining the additional medical evidence, the Board is satisfied there was compliance with this remand directive. See Stegall v. West, 11 Vet. App. 268 (1998) (indicating the Veteran is entitled, as a matter of law, to compliance with a remand directive and that the Board, itself, commits error in failing to ensure this compliance). See also Dyment v. West, 13 Vet. App. 141, 146-47 (1999); and D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (discussing situations when it is acceptable to have "substantial", though not "exact", compliance with a remand directive). In summary, the Board finds that "it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claim." See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances as to when a remand would not result in any significant benefit to the Veteran). Secondary Service Connection Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). A claim for secondary service connection generally requires competent evidence of a causal relationship between the service-connected disability and the nonservice-connected disease or injury. Jones (Wayne L.) v. Brown, 7 Vet. App. 134 (1994). There must be competent evidence of a current disability; evidence of a service-connected disability; and competent evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). 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 sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Additionally, when aggravation of a nonservice-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 71 Fed. Reg. 52744-52747 (Sept. 7, 2006). Effective October 10, 2006, VA amended 38 C.F.R. § 3.310 to implement the Court's decision in Allen, which, as noted above, addressed the subject of the granting of service connection for the aggravation of a nonservice-connected condition by a service-connected condition. See 71 Fed. Reg. 52,744-47 (Sept. 7, 2006). The existing provision at 38 C.F.R. § 3.310(b) was moved to sub-section (c). Under the revised section 3.310(b), the regulation provides that: Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. Part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. See 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310(b) (2011)). While the overall intention of the amendment to 38 C.F.R. § 3.310(b) was to implement the Allen decision, the amended 38 C.F.R. § 3.310(b) clearly institutes additional evidentiary requirements that must be satisfied before aggravation may be conceded and service connection granted. In addressing the imposition of this new evidentiary requirement, the regulatory comments cite to 38 U.S.C. § 501 as the supporting authority, and not Allen. See 71 Fed. Reg. 52,744-45 (Sept. 7, 2006). A review of the regulatory comments make clear that, ultimately, it is the Veteran's responsibility to support his or her claim by providing evidence of the baseline level of severity, and that it is not enough merely that an examiner concludes that there is "aggravation." See 71 Fed. Reg. 52,745 (Sept. 7, 2006). In sum, 38 C.F.R. § 3.310(b) appears to place substantive evidentiary restrictions on a veteran before aggravation may be conceded, and these restrictions appear to have no basis in the Allen decision itself. However, in this case, the Veteran's claim was filed prior to the effective date of the revised regulation (October 10, 2006). As such, the Board finds that the prior version of the regulation is more advantageous to the Veteran and should be applied. When a regulation changes and the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and after, the effective date of the change. See generally, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003. In order to establish service connection for a claimed disability on a secondary basis, there must be (1) competent evidence of a current disability; (2) a service-connected disability; and (3) competent evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin. A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). However, 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, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). When, for example, a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As held in Davidson, section 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. See also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence" such as actual treatment records). The Veteran is competent to report that which he can observe and feel through the senses. See Layno. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Once evidence is determined to be competent, the Board must determine whether the evidence also is credible, as only then does it ultimately have probative value. See Layno (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")); Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons or bases for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). To this end, the Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court), citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court similarly has declared that, in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing when he/she has testified. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, aff'd per curiam, 78 F.3d 604(Fed. Cir. 1996). See, too, Macarubbo v. Gober, 10 Vet. App. 388 (1997) (similarly holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record, medical and lay, and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. The Veteran contends that his left knee disability, status post total arthroplasty as well as instability, have resulted in low back, neck, shoulder, and psychiatric disabilities, due to the strain and falls caused by his knee disability. Although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins as well as his symptoms, the Veteran is not competent to provide evidence as to more complex medical questions such as the ones before the Board at this time regarding whether his claimed disabilities, are proximately due to, the result of, or aggravated by the service-connected left knee disability. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Thus, the Board remanded this case to obtain a medical opinion from a medical professional who has the competence to make this assessment. At the time the case was remanded, the Veteran's left knee disability had not been service-connected. The following directives were provided by the Board: 1. Obtain a medical addendum report from the VA examiner who conducted the March 2011 VA examination, or, if this examiner is unavailable, from another VA examiner. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current left and/or right knee disability had its clinical onset during service or is related to any in-service disease, event, or injury, to include the inservice left knee sprain. The examiner should specifically address the 1966 private medical records following the Veteran's MVA. In particular, the notations that the Veteran had had "thick knees since 1954," and that his knees "give out from under him very easily" should be addressed. As well, the examiner should take into consideration and discuss the lay evidence which states that the Veteran had bilateral knee disabilities when he separated from service. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 2. If the VA examiner provides a medical addendum which supports the claim of service connection for a left knee disability, the Veteran should be afforded a VA examination to address his other claimed disabilities. The record (both the claims file and virtual records) must be made available to the examiner and the examiner should indicate in his/her report whether or not the claims file was reviewed. Any indicated tests, including X-rays if indicated, should be accomplished. Based on a review of the claims file and any examination findings, the examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current right knee, low back, neck, and bilateral shoulder disabilities as well as psychiatric disorder, are proximately due to, or the result of the left knee disability. The examiner should also provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current right knee, low back, neck, bilateral shoulder, and psychiatric disabilities, are permanently aggravated (chronically worsened) by the Veteran's left knee disability. If such aggravation is found present, the examiner should address the following medical issues: (1) The baseline manifestations of the Veteran's current right knee, low back, neck, bilateral shoulder, and/or psychiatric disabilities found present prior to aggravation; (2) The increased manifestations which, in the examiner's opinion, are proximately due to the left knee disability based on medical considerations. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 3. The AMC should review the medical opinion(s) obtained above to ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, the AMC should return the case to the examiner for completion of the inquiry. The VA examinations were performed in March 2013. The findings are discussed below. Low Back Private medical records reflect that the Veteran underwent a laminectomy in March 1980 which relieved back and leg complaints. However, in January 1982, he reported the same complaints. A myelogram showed a large defect at L5-S1 on the left side. He underwent another laminectomy which removed a huge herniated lumbar disc. Postoperatively, the Veteran was noted to do well. In August 1982, the Veteran underwent a VA examination. Physical examination yielded a diagnosis of status post lumbar laminectomy at L5-S1. In November and December 1990, the Veteran reported having back pain and muscle spasm was noted. In October 1992, the Veteran was treated for chronic back syndrome. In January 1993, the Veteran slipped on ice and injured his spine. He was diagnosed with lumbar cervical muscle strain. In September 1993, the Veteran indicated that he was experiencing a persistent increase in his back pain and the examiner noted that he had suffered an exacerbation of his osteoarthritis of the back. VA records dated in 2011 noted that the Veteran had a L3 vertebral fracture. In October 2011, he had back pain after lifting heavy bags. Also, other October 2011 records documented that the Veteran had severe radiculopathy of bilateral L3 and left S1 due to recurrent disc joint disease as well as marked radiculopathy of left L2, bilateral L4, and right L5 due to facet joint disease. The Veteran also had mild radiculopathy of right S2. In February 2012, the Veteran testified at a Board hearing. At that time, he reported that he had suffered falls due to his knee disability in the past which resulted in back problems. In order to resolve whether the Veteran's back disability is etiologically related to his left knee disability, the Veteran was afforded a VA examination in March 2013. The current diagnoses included compression fracture, healed; lumbar spondylosis, and lumbar radiculopathy. The Veteran reported to the examiner that he did not sustain a back injury during service, but believed that he had back disability due to falls he sustained related to his left knee. However, after reviewing the record and examining the Veteran, the examiner opined that the low back conditions were more likely due to aging and were unrelated to his knee conditions. Therefore, his low back disabilities were less likely than not caused or exacerbated (aggravated) by his left knee condition or service. The Board attaches significant probative value to this VA opinion, and the most probative value in this case, as it is well reasoned, detailed, consistent with other evidence of record to the extent there often has not been any underlying diagnosis, and included consideration of the Veteran's relevant medical history, including his symptoms and reference to his left knee disability. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). See also Neives-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (indicating most of the probative value of an opinion comes from its underlying reasoning, not just from mere review of the claims file, although that, too, has its importance if evidence in the file may affect the underlying basis of the opinion such as by revealing relevant facts). The VA examiner based the opinion on a review of the claims file, but also on the Veteran's history as recounted by him and as shown in the record, plus personal examination of him. Hence, there were multiple supporting bases for the opinion. The examiner concluded that the current back diagnoses were etiologically unrelated to the service-connected left knee disability. Accordingly, service connection on a secondary basis is not warranted. Neck VA records reflect that a March 1986 cervical spine x-ray was normal. A December 1987 cervical spine x-ray also revealed no abnormalities. A December 1987 electromyography revealed mild ongoing denervation of the left deltoid. It was noted that the findings were suggestive of a left C5 radiculopathy. In February 1988, the Veteran underwent nerve conduction studies as well as a myelogram and computerized tomography of his neck after reported cervical radiculopathy of two years' duration. The electromyography revealed mild ongoing denervation of the left deltoid. The myelogram revealed bilateral cervical root sleeve abnormalities. The computerized tomography revealed very minimal foraminal stenosis due to the unconvertebral spurring at the C4-5 and C5-6 levels. There was mild bilateral effacement of the associated root sleeves. There was also very mild ligamentous enfolding at the C6-7 level which did not appear to cause central stenosis. The diagnosis was cervical spondylosis. In March 1990, the Veteran complained of right arm pain which was noted to be a possible symptom related to arthritic changes of the cervical spine. In January 1993, the Veteran slipped on ice and injured his spine. He was diagnosed with lumbar cervical muscle strain. Medical records dated in 2011 confirmed that the Veteran had neurological impairment related to his neck. In February 2012, the Veteran testified at a Board hearing. At that time, he reported that he had suffered falls due to his knee disability in the past which resulted in neck problems. In order to resolve whether the Veteran's neck disability is etiologically related to left knee disability, the Veteran was afforded a VA examination in March 2013. The current diagnosis was cervical spondylosis. The Veteran reported to the examiner that he did not sustain a neck injury during service, but believed that he had neck disability due to falls he sustained related to his left knee. However, after reviewing the record and examining the Veteran, the examiner opined that current disability was more likely due to aging and was unrelated to his knee conditions. Therefore, his neck disability was less likely than not caused or exacerbated (aggravated) by his left knee condition or service. Again, the VA examiner's opinion is more probative than the Veteran's opinion that his falls due to his knee disability resulted in neck pathology. The VA examiner had an opportunity to fully review the Veteran's history and record, examine the Veteran, consider his contentions, and provide a current diagnosis, which stated that the current disability is not etiologically related to the claimed knee disability. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (holding that the probative value of medical opinion evidence is based on the personal examination of the patient, the knowledge and skill in analyzing the data, and the medical conclusion reached); see also Nieves- Rodriguez (the probative value of a medical opinion comes from when it is factually accurate, fully articulated, and has sound reasoning for the conclusion.) Accordingly, service connection is not warranted on a secondary basis for neck disability. Shoulders VA records show that a March 1986 right shoulder x-ray revealed no abnormalities. In December 1993, the Veteran reported that he had right shoulder and arm pain. X-rays revealed minimal changes of arthritis with some mild irregularity of the bony spaces in the joint regions. In February 2012, the Veteran testified at a Board hearing. At that time, he reported that he had suffered falls due to his knee disability in the past which resulted in shoulder problems. In order to resolve whether the Veteran's shoulder disability is etiologically related to his left knee disability, the Veteran was afforded a VA examination in March 2013. The current diagnosis was bilateral glenohumeral and acromioclavicular degenerative joint disease. The Veteran reported to the examiner that he did not sustain shoulder injury during service, but believed that he had shoulder disability due to falls he sustained related to his left knee. However, after reviewing the record and examining the Veteran, the examiner opined that current disability was more likely due to aging and was unrelated to his knee conditions. Therefore, his neck disability was less likely than not caused or exacerbated (aggravated) by his left knee condition or service. The VA examiner's opinion was based on review of the Veteran's record and included an examination of the Veteran, rendering it probative. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The opinion of this VA physician is more probative than the Veteran's opinion because the examiner has a medical background and based his opinion on a fully informed pertinent factual premises, i.e., the complete medical history in this case, and provided rationale for the opinion. As the most probative evidence establishes that current bilateral shoulder disability is not etiologically connected to the claimed left knee disability, service connection is not warranted on a secondary basis. Psychiatric In order to resolve whether the Veteran has a psychiatric disability, and, if so, if it is etiologically related to knee disability, the Veteran was afforded a VA examination in March 2013. At that time, it was noted that although the Veteran was dealing with some ongoing medical issues and physical limitations, he was generally functioning well with no reports of any significant psychiatric concerns. Any present symptoms were noted to be transient and expectable reactions to psychosocial stressors causing no more than slight impairment in functioning. In summary, the examiner indicated that the Veteran denied any current psychiatric issues and significant problems in the past, other than a historical period where the Veteran was drinking heavily and which he got under control 25 years ago. Overall, the Veteran was not reporting any symptoms that rose to the level of a formal psychiatric disorder with no significant mood disturbances. He was functioning well, as previously noted. No diagnosis was made of a current psychiatric disability. The Court consistently has held that, under the law, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). This principle has been repeatedly reaffirmed by the Federal Circuit Court, which has stated, "a Veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the Veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed). In Brammer v. Derwinski, 3 Vet. App. 223 (1992), the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. See also Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). A "current disability" means a disability shown by competent evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). The Board attaches significant probative value to the VA opinion as a psychiatric evaluation was performed on the Veteran by a medical professional. This opinion is the most probative evidence regarding the Veteran's psychiatric state and is uncontradicted by equally probative evidence. The Board finds that the VA examiner's opinion is more probative than the Veteran's personal assertions that he has actual psychiatric pathology because the examiner has medical expertise that the Veteran does not possess. Thus, the most probative evidence establishes there is no present disability. Health professionals are experts and are presumed to know the requirements applicable to their practice and to have taken them into account in providing a diagnosis, or the lack thereof in this case. See generally Cohen v. Brown, 10 Vet. App. 128, 137 (1997). Absent a current diagnosis, service connection is not warranted. (Continued on the Next Page) ORDER Service connection for status post lumbar laminectomy, L5-S1, to include arthritis, claimed as secondary to a service-connected left knee disability, is denied. Service connection for a neck disability, characterized as arthritis, claimed as secondary to a service-connected left knee disability, is denied. Service connection for a bilateral shoulder disability, claimed as secondary to a service-connected left knee disability, is denied. Service connection for an acquired psychiatric disability, other than PTSD, claimed as secondary to a service-connected left knee disability, is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs