Citation Nr: 1319296 Decision Date: 06/13/13 Archive Date: 06/21/13 DOCKET NO. 09-27 971A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for a bilateral knee disability. 2. Entitlement to service connection for a bilateral ankle disability. REPRESENTATION Appellant represented by: Arizona Department of Veterans Services WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Keyvan, Associate Counsel INTRODUCTION The Veteran was in the United States Air Force from June 1955 to May 1961, and had certified active duty from August 1957 to May 1961. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating action of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. In that decision, the RO denied claims for service connection for bilateral knee and bilateral ankle disabilities. The Veteran received a hearing before the undersigned in March 2011. A transcript of the hearing is associated with the file. This claim was remanded in May 2011 and July 2012 for additional evidentiary development. Specifically, the Board instructed the Agency of Original Jurisdiction (AOJ) to make additional attempts to locate the Veteran's service treatment records, and retrieve private treatment records from South Bay Medical Center pertaining to treatment of the Veteran's knees and ankles between 1969 and 1970. The Board also directed the AOJ to schedule the Veteran for a VA examination to determine the nature and etiology of his bilateral knee and ankle disorders. The Board finds that the AOJ has complied with all of the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). In June 2013, the Board granted a motion to advance the appeal on the Board's docket due to the Veteran's age pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran's bilateral knee disorder, to include degenerative joint disease (DJD) in the right and left knee, did not manifest in service or one year thereafter, and the Veteran has not been shown to have a bilateral knee disorder that is causally or etiologically related to military service. 2. The Veteran's currently diagnosed ankle disorders were first identified many years after service and are not shown to be related to his military service. CONCLUSIONS OF LAW 1. The Veteran's bilateral knee disorder, to include DJD in the right and left knee, was not incurred in active service, nor may arthritis of the knees be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1131, 1112, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). 2. A bilateral ankle disability was not incurred in or aggravated by active service. §§ 1101, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist At the outset, the Board will address the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), enacted in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)(2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). In this case, the Board finds that all notification and development action needed to arrive at a decision has been accomplished. In this respect, through a November 2007 notice letter, the Veteran received notice of the information and evidence needed to substantiate his claims. Thereafter, he was afforded the opportunity to respond. Hence, the Board finds that the Veteran has been afforded ample opportunity to submit information and/or evidence needed to substantiate his claims. The Board finds that the November 2007 notice letter satisfies the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). In the letter, the RO also notified the Veteran that VA was required to make reasonable efforts to obtain medical records, employment records, or records from other Federal agencies. The RO also requested that the Veteran identify any medical providers from whom he wanted the RO to obtain and consider evidence. Proper VCAA notice must inform the claimant of any information and 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. See Pelegrini v. Principi, 18 Vet. App. 112, 121 (2004). See also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (to be codified at 38 C.F.R. § 3.159) (removing the prior requirement that VA specifically ask the claimant to provide any pertinent evidence in his possession). These requirements were met by the aforementioned November 2007 letter. Further, the Veteran was provided notice regarding an award of an effective date and rating criteria in the November 2007 letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 472 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Nothing about the evidence or any response to the RO's notification suggests that the case must be re-adjudicated ab initio to satisfy the notice requirements of the VCAA. The Board also points out that there is no indication that any additional action is needed to comply with the duty to assist in connection with the claims on appeal. Review of the Veteran's claims file reflects that a response to the RO's request for records stated that the Veteran's service treatment records were "fire-related." In other words, they were involved in a 1973 fire at the National Personnel Records Center (NPRC) in St. Louis, Missouri, and are unavailable. When a claimant's treatment records are lost or destroyed, the VA has a "heightened" duty to assist in the development of the claims. See Washington v. Nicholson, 19 Vet. App. 362. 369-70 (2005). See also 38 C.F.R. § 3.159(c). To help assist the Veteran in reconstructing his medical records, the RO, in the November 2007 letter, asked the Veteran to complete a VA NA Form 13055, and, in so doing, identify the name of the organization and unit he served in during his period of active duty, the dates of his treatment, and the name and location of the hospital/dispensary where he was treated. The Veteran completed this form and specifically indicated that he received medical treatment for an in-service fall at the Air Terminal Squadron at Travis Air Force Base (AFB) on and after March 1958. To help assist the Veteran retrieve his medical records, requests utilizing this information were submitted under Personnel Information Exchange System (PIES) in November 2007, January 2008, and March 2008. Negative responses were generated in June 2008 and indicated that there were no additional service treatment records on file for the Veteran and additional information regarding the Veteran's unit assignment was necessary. In letters dated in July and August 2008, the RO informed the Veteran that they had not been able to secure his service treatment records, and asked him to furnish any documents that could substitute for service treatment records (original or copies) in his possession. The Veteran did not respond or provide any additional information or evidence. In August 2008, the RO issued a Formal Finding on the Unavailability of service treatment records from the Veteran's period of service, and listed the various attempts made to locate the Veteran's records. Based on testimony provided by the Veteran at his March 2011 hearing, and pursuant to the May 2011 Board remand, the Agency of Original Jurisdiction (AOJ) submitted another PIES request in May 2011, and specifically requested any inpatient clinical records pertaining to treatment of the Veteran's knees and ankles at the Travis AFB Hospital and/or the David Grant U.S. Air Force (USAF) Hospital anytime between February 1, 1958 to April 30, 1958. A June 2011 response indicated that no additional records were located. Another request utilizing this same information and also including the Veteran's unit assignment during that time period was also initiated in May 2011 and returned no records. The February 2012 response specifically indicated that no Air Force sick reports were on file after June 1951. Pursuant to the July 2012 Board remand, the AOJ submitted one final PIES request in August 2012 and requested any medical, dental and Surgeon General Office (SGO) records pertaining to treatment of the Veteran's knees and ankles, and/or any sick/morning records from the Travis AFB dated on March 15, 1958 pertaining to treatment for the knees and ankles. A negative response was generated in September 2012 and indicated that a search for these records located no additional records. In March 2013, VA issued a Formal Finding on the Unavailability of Service Treatment Records from the Veteran's period of service, and listed the various attempts made to locate the Veteran's records. According to the memorandum, all procedures to obtain records pertaining to the Veteran had been correctly followed, all efforts to obtain the needed information had been exhausted, and any further attempts were futile. Records of the Veteran's post-service treatment at the VA Medical Center (VAMC) in Phoenix, Arizona have been associated with the claims file and were reviewed by the RO in connection with the Veteran's claim. Additionally, the Veteran has submitted written statements in support of his claims. The Board notes that the Veteran is currently in receipt of Social Security Administration (SSA) benefits; however a March 2011 letter from SSA states that no medical records are available. Pursuant to the May 2011 and July 2012 Board remands, attempts were made to retrieve the Veteran's private treatment records from Kaiser Permanente Hospital (also identified as South Bay Medical Center) in Harbor City, California from 1969 to 1970. Upon receipt of the first completed medical release form from the Veteran, the Appeals Management Center (AMC) sent Kaiser Permanente Hospital a letter dated in July 2011, and requested any treatment records pertaining to the Veteran's bilateral knee and ankle condition. An August 2011 response from Kaiser Permanente indicated that additional information, to include the Veteran's Kaiser Permanente medical record number, was necessary before a search for the Veteran could be undertaken. In a July 2012 letter, the Veteran was informed that he needed to provide his Kaiser Permanente medical record number before a search for his records could take place. While the Veteran completed the release form once again and included the name and address of the medical center where he received treatment, as well as his dates of treatment, he did not provide his Kaiser Permanente medical number. Utilizing the information provided in the completed VA Form 21-4121, the AMC sent additional letters to South Bay Medical Center requesting any records pertaining to the Veteran's bilateral knee and ankle disabilities. A January 2013 response from Kaiser Permanente once again indicated that additional information, including the Veteran's Kaiser Permanente Medical Record number, was necessary before a search for the Veteran could be undertaken. In a February 2013 statement, the Veteran, through his representative, acknowledged the efforts made by the AMC in attempting to secure his records, and further indicated that all of his efforts e to obtain his medical records from South Bay Medical Center had been futile. The Veteran asked that the Board make a decision on his claim based on the available evidence of record. Based on the foregoing, the Board concludes that VA has done everything reasonably possible to assist the Veteran in obtaining any outstanding service treatment records and private treatment records and the Veteran has not contended otherwise. The duty to assist also includes obtaining a medical examination/opinion when such is necessary to make a decision on the claim, as defined by law. Pursuant to the July 2012 Board remand, the Veteran underwent VA examinations in connection with his claimed disorders in August 2012; reports of the examinations are of record. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the Board finds that the VA examinations obtained in this case are adequate, as they are predicated on a physical examination as well as consideration of the medical records in the Veteran's claims file and the Veteran's reported history. The opinions consider all of the pertinent evidence of record, to include statements given by the Veteran at the time of the VA examinations, and provide a complete rationale for the opinions stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the claims on appeal has been met. 38 C.F.R. § 3.159(c)(4). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome here, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Factual History The Veteran contends that his current bilateral knee and ankle disabilities were incurred during his period of active service. Specifically, the Veteran contends that he was unloading cargo from a C-124 cargo plane when he fell over 20 feet and hit the ground. The Veteran asserts that his current disabilities are related to this in-service occurrence. See September 2007 claim; see also November 2007 and August 2009 statements of Veteran and March 2011 Hearing Transcript (T.), pp. 3-4. A. Bilateral Knee Disability The evidence does not show that the Veteran sought treatment for his bilateral knee disorder until many years after his separation from service. Indeed, the first post-service medical evidence of record reflecting signs of a knee disorder are hospital records dated in May 2006 which show that the Veteran dislocated his right knee which led to an associated popliteal injury. These records further reflect that the Veteran underwent a superficial femoral artery-popliteal artery bypass procedure using reverse saphenous vein graft of the right leg. Report of the May 2006 right knee magnetic resonance imaging (MRI) revealed a "[f]ull-thickness anterior cruciate ligament tear and possible injury of the insertion segment of the posterior cruciate ligament." At the September 2006 VA Orthopedic Consultation, the treatment provider noted that the Veteran was totally disabled secondary to the "pan ligamentous instability" in his right knee. It was further noted that X-rays of the knee showed DJD. Further review of the post-service medical evidence of record reflects that the Veteran was first diagnosed with minimal incipient degenerative joint disease in his left knee at the August 2012 VA examination. In the August 2007 VA progress report, the staff physician, S.B., M.D., listed all of the Veteran's active medical problems, and noted that he had experienced a dislocated knee, a sprain of the lateral collateral and medial collateral ligaments and a sprain of the cruciate ligament. According to Dr. B., "it is more than 50 [percent] certain that [the Veteran's] knee and ankle problems, with resultant balance problem, is related to the accident and injury he had while on active duty." The Veteran was afforded a VA examination in connection to this claim in August 2012, at which time the VA examiner reviewed the Veteran's claims file and medical history. During the examination, the Veteran asserted that his bilateral knee disability had its onset in service after he reportedly fell out of a cargo plane and fell close to 30 - 40 feet before hitting the ground. The Veteran further stated that he was hospitalized for a period of ten days before he could return to his military assignment. According to the Veteran, he started tripping two to three times per year for no apparent reason after this incident. The Veteran denied receiving any treatment for his knees after service, but did note that he sought treatment at Kaiser in 1969 when his legs went out from under him after stepping out of truck. The Veteran also described several incidents which took place between 2006 to 2007 wherein his legs would "go out from under him" causing him to fall. According to the Veteran, prior to the 2006 surgery, the only treatment he received for his bilateral knee condition consisted of crutches, knee braces and some pain medication. Based on his discussion with, as well as his evaluation of the Veteran, the VA examiner diagnosed the Veteran with mild degenerative joint disease of the right knee and minimal incipient degenerative joint disease of the left knee. The examiner further opined that these disorders were less likely than not to have been incurred in or caused by an in-service injury, event or illness. According to the examiner, there are no records to support the Veteran's assertions of an in-service injury, and further no records after service to support his allegations of tripping on multiple occasions. The VA examiner further acknowledged the August 2007 opinion issued by Dr. B., but noted that this opinion was not supported "by any detailed history" or "physical exam" and as such was not substantiated by the record. The examiner further took note of the August 2003 VA primary care note which was clear for a history of lower extremity problems. B. Bilateral Ankle Disability The evidence does not show that the Veteran sought treatment for his bilateral ankle disorder until many years after service. Indeed, a July 2005 VA treatment note is the first post-service medical evidence of record reflecting the Veteran's complaints of chronic ankle problems, to include symptoms of instability and pain, which he related to a 40 foot fall from an airplane in service. The Veteran also relayed a history of two to three falls a month as a result of his ankle instability, and reported that his most recent problems have been ongoing for the past year. An X-ray of the right ankle was clear for any fracture or osseous lesions and revealed normal alignment. However, the X-ray report did show a small exostosis at the medial malleolus at the base of the tibial styloid. Based on his physical evaluation of the ankle, as well as his review of the diagnostic records, the staff podiatrist assessed the Veteran with bilateral ankle joint instability that was greater in the right ankle. At the August 2012 VA examination, the Veteran attributed his ankle disabilities to the same in-service fall he relates his current bilateral knee condition to. The Veteran also reported that he began seeking treatment for his ankle condition at Kaiser Permanente between 1971 to 1975 and during the 1980's after service. Based on his discussion with, as well as his evaluation of the Veteran, the VA examiner diagnosed the Veteran with a right ankle sprain and a small exostosis of the medial malleolus in the left ankle. According to the examiner, these ankle disorders were less likely than not incurred in or caused by the claimed in-service injury, event or illness. When asked to provide a rationale for his opinion, the examiner referred to the same explanation provided for the etiological opinion regarding the bilateral knee disability. The Board acknowledges part six of the Medical Opinion section wherein the examiner marked that the "claimed condition, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness." It is clear that this was a typographical error as it was inconsistent with the earlier finding and did not include a rationale, as would have been necessary to support the conclusion. The evidence of record is devoid of any evidence indicating that the Veteran had an ankle disability prior to service, nor has the Veteran asserted as such. There are no pre-service records associated with the claims file reflecting that the Veteran experienced problems with his ankles prior to his enlistment in service. Moreover, throughout the appeal, the Veteran has repeatedly related his bilateral ankle disorder to his claimed in-service fall. The Veteran himself testified that he did not have any problems with his joints or lower extremities prior to the alleged incident in 1958. See T., p. 16. III. Analysis Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Generally, in order to establish direct service connection for a disorder, there must be (1) medical evidence of the current disability; (2) medical, or in certain circumstances, lay evidence of the in-service incurrence of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Subsection (a) also refers to "each disabling condition...for which [a veteran] seeks a service connection" and states that "[d]eterminations as to service connection will be based on review of the entire evidence of record." See Walker. A second way to establish direct service connection is set forth in § 3.303(b). In Walker, the Court of Appeals for the Federal Circuit (Federal Circuit) found that, unlike subsection (a), which is not limited to any specific condition, subsection (b) is restricted to chronic diseases. "If a veteran can prove a chronic disease 'shown in service,' and there are no intercurrent causes, the manifestations of the chronic disease present at the time the veteran seeks benefits establish service connection for the chronic disease. By treating all subsequent manifestations as service-connected, the veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability compensation is sought. In short, there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. In addition, the Federal Circuit found that subsection (b) provides a second route by which service connection can be established for a chronic disease, which is if "evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not 'shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,' i.e., 'when the fact of chronicity in service is not adequately supported,' then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Id. Furthermore, the Federal Circuit held that that the term "chronic disease" as set forth in subsection (b) is properly interpreted as being constrained by § 3.309(a) in that the regulation is only available to establish service connection for the specific chronic diseases listed in § 3.309(a) regardless of the point in time when a veteran's chronic disease is either shown or noted. Id. Certain chronic diseases, including arthritis, may be presumed to have been incurred during service if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307(a)(3); 3.309(a) (2012). As discussed above, the Veteran's service treatment records are not available and are presumed destroyed. The Board notes that VA has heightened duties when the Veteran's service treatment records are unavailable. See O'Hare v. Derwinski, 1 Vet. App. 365 (1991). However, the case law does not establish a heightened benefit-of-the-doubt standard, only a heightened duty of the Board to consider applicability of the benefit-of-the-doubt doctrine, to assist the claimant in developing the claim, and to explain its decision. See Cromer v. Nicholson, 19 Vet. App. 215 (2005). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for his knee and ankle disorders. Because the Veteran's service treatment records are unavailable for review, the Board must base its decision on other available evidence. While the Veteran has related his claimed knee and ankle disorders to an in-service injury and has claimed to experience problems associated with his knees and ankles since this in-service occurrence, the record shows that he did not file a claim for service connection for these disorders until September 2007, over forty-six after his separation from service. The Board further emphasizes the multi-year gap between the Veteran's discharge from active duty service (1961) and the post-service medical evidence reflecting treatment for, and diagnoses of bilateral knee and ankle disorders. As previously noted, the Veteran did not begin seeking treatment for right knee problems until dislocating his right knee in 2006, and the record does not reflect a diagnosis of a right knee disability until 2006, nearly forty-five years after his separation from service. Additionally, the treatment records are clear for any complaints of, or treatment provided for, a left knee condition until August 2012, more than fifty-one years after his separation from service. Furthermore, the Veteran did not begin seeking treatment for ankle problems, and was not assessed with bilateral ankle joint instability until July 2005, over forty-four years after his separation from service. A prolonged period without medical complaint can be considered, along with other factors concerning the claimant's health and medical treatment during and after military service, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability which still exists currently. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Next, service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. Where the Board is presented with conflicting medical evidence, it is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). In this regard, the Board notes that the Federal Circuit and the Court have both specifically rejected the "treating physician rule." See White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001); Guerrieri v. Brown, 4 Vet. App. 467 (1993). Instead, the Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one medical professional's opinion over another, depending on factors such as reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994); see also Wensch v. Principi, 15 Vet. App. 362, 367 (2001) (it is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases). The Board finds the August 2007 VA medical opinion to be insufficient to grant the Veteran's claims for several reasons. First, Dr. B. did not provide an explanation as to why the Veteran's knee and ankle disabilities were related to the reported in-service incident, especially in light of the post-service injuries the Veteran was receiving treatment for. A medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions," see Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007), and the "examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two," Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Secondly, the opinion is clearly based solely on the Veteran's reported history, since there is no indication that Dr. B. reviewed the Veteran's claims file in conjunction with the opinion provided. The fact that Dr. B. accepted the Veteran's statements as to the relationship between his complaints of knee and ankle pain and a reported in-service injury is irrelevant because, in this case, the Board concludes that the Veteran's reported history is not credible and not probative evidence. In this regard, turning to the March 2011 hearing transcript, the Board acknowledges the Veteran's testimony wherein he provided the specific date of his in-service injury. See T., p. 5. However, the Veteran did not demonstrate a good memory when it came to subsequent questions concerning his period of service. For example, the Veteran could not recall the specific squadron number he was assigned to at the time of his reported injury. See T., p. 10. In addition, his recollections regarding his ongoing symptoms after service, as well as the places and dates surrounding his post-service treatment were vague. Indeed, when asked about the most recent time he received treatment for his lower extremities, the Veteran could not recall the name of the hospital where he received treatment. See T., p. 13. These factors diminish the reliability of any current assertions regarding an in-service event that reportedly took place more than fifty years ago. An August 2003 VA progress note reflects that the Veteran had an opportunity to provide his medical history and describe any ongoing health-related problems he had been experiencing when first presenting at the Phoenix VAMC to establish VA care. While the Veteran reported a history of various health-related ailments, and further noted to have fractured his wrist when asked to provide a history of serious injuries, he denied any musculoskeletal disease and failed to report any problems in his lower extremities. He has described treatment for these problems many years earlier, but has not cooperated in giving complete information necessary to obtain this potentially supporting documentation. In light of these factors, the Board does not find the Veteran credible regarding his report of an in-service fall which resulted in injuries to his bilateral knees and ankles. The Board is not bound to accept medical opinions that are based on history supplied by the Veteran, where that history is unsupported by the medical evidence or based upon an inaccurate factual background. Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458, 460- 61 (1993). In this case, the physician did not have the benefit of review of the claims folder for a comprehensive review of the Veteran's clinical history. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). As such, the Board finds this opinion to be of less probative value. The Board concludes that the August 2012 VA examination is adequate upon which to base a determination. This examination report included a complete physical examination of the Veteran and a review of the Veteran's claims file. In addition, the August 2012 VA examiner based his opinion on an accurate background and the relevant historical facts, and offered a thorough rationale for the opinions reached that is supported by the evidence of record. The examiner specifically took note of the post-service evidence of record which was clear for any evidence that could support the Veteran's allegations of tripping on multiple occasions after service. The examiner also acknowledged the August 2007 opinion issued by Dr. B., and concluded that this opinion was not substantiated by the evidence of record as it lacked the benefit of a physical examination of the Veteran as well as a discussion of the Veteran's medical history. The examiner also referenced the August 2003 primary care report which was clear for a history of lower extremity problems. Thus, in this case, when weighing the evidence of record, the Board finds the medical opinion of the August 2012 VA examiner more probative on the question of medical nexus with respect to any relationship between the Veteran's current bilateral knee and ankle disabilities and his active military service. In so finding, the Board reiterates that the VA examiner's opinion was based on a complete review of the claims file, the Veteran's reported history, and a clinical evaluation. The Board has also considered the Veteran's contentions that a relationship exists between his current knee and ankle disorders and service. Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is 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), Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991)("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, however, although the Veteran is competent to describe symptoms of a knee and ankle disorder, he is not competent to comment on the etiology of such disorders. While a layperson can provide evidence as to some questions of etiology or diagnosis, the question of a medical relationship between a current diagnosed disorder and service, which would require more than direct observation to resolve, is not in the category of questions that lend themselves to resolution by lay observation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), Barr v. Nicholson, 21 Vet. App. 303, 309 (2007), Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). The Veteran is competent to report symptoms of knee and ankle pain because such actions come to him through his senses and, as such, require only personal knowledge rather than medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Veteran is not competent to opine on the question of etiology and, therefore, his statements asserting a relationship between his current bilateral knee and ankle disorder and service, do not constitute competent medical evidence on which the Board can make a service connection determination. As for the Veteran's complaints of continuing pain and discomfort in the knees and ankles since service, the Board notes that it may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints of or treatment for the relevant condition or symptoms. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37. Notwithstanding that fact, the lack of contemporaneous medical records is something that the Board can consider and weigh against a Veteran's lay evidence. Id. According to the Veteran's statements, his bilateral knee and ankle disabilities had their onset in service, and he has continued to experience symptoms from these disabilities since that time. In that connection, the record discloses forty-five years from the time the Veteran separated from active service and the first medical evidence of record indicating that he was experiencing knee problems in May 2006. The record also discloses forty-four years from the time the Veteran separated from active service and the first symptoms of ankle trouble and diagnosis of a bilateral ankle disability in July 2005. Therefore, continuity of symptomatology is not established based on the clinical evidence alone. The Veteran claims that he received treatment at a Kaiser Permanente treatment facility sometime between 1969 to 1970 upon injuring his lower extremities when his legs gave out from under him. See T., p. 14. The Veteran reported at the August 2012 VA examination that he received treatment for his ankles at Kaiser Permanente between 1971 to 1975 and during the 1980's. Unfortunately, despite numerous attempts, VA was unable to retrieve any medical records from Kaiser Permanente Hospital (South Bay Medical Center) pertaining to treatment of the Veteran's knees and ankles. The Veteran has not been entirely cooperative and has not provided information that would facilitate the ordering of these documents. Moreover, the Board notes that the Veteran had the opportunity to discuss his ongoing knee and ankle problems during the August 2003 primary care visit, but chose not to do so. He described a myriad of other health-related ailments, and noted to have fractured his wrist when asked to describe his previous injuries, but denied a history of musculoskeletal disease and failed to mention his bilateral knee and ankle problems. It should be noted that a missed opportunity to report and seek treatment for his ankles and knees weighs against the Veteran's current assertions. The Board finds it likely that if knee pain and ankle persisted or a knee or ankle disability was present, the Veteran would have mentioned this during an initial primary care visit specifically designed to understand and take into account his medical history. As such, his claim of continuous knee and ankle problems since service is not credible. In light of these facts, service connection is not warranted under 38 C.F.R. § 3.303(b). It is for these reasons, as well, that the lay statements alleging post-service continuity of symptomatology are rejected as not supported by the record. In addition, the Board finds that service connection on a presumptive basis is not warranted as the medical evidence fails to establish by x-ray evidence that the Veteran had degenerative changes in his knees within one year of his discharge from active service in May 1962. Accordingly, the Board concludes that the preponderance of the evidence is against finding that service connection is warranted for the Veteran's current bilateral knee and ankle disorders on a direct basis. The preponderance of the evidence being against these service connection claims, the benefit of the doubt doctrine is not applicable. Consequently, these issues must be denied. ORDER Entitlement to service connection for a bilateral knee disability is denied. Entitlement to service connection for a bilateral ankle disability is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs