Citation Nr: 1320837 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 10-11 918 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a right knee disability, to include as secondary to a low back disability. 3. Entitlement to service connection for a left knee disability, to include as secondary to a low back disability. 4. Entitlement to service connection for bilateral hearing loss. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran served on active duty from April 1953 to August 1958, with subsequent Reserve service. 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). This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied service connection for the disabilities on appeal. This appeal was previously remanded by the Board in June 2012 and March 2013 for additional development. That development has been completed, and the case returns to the Board for further review. A portion of the Veteran's records are contained in the Virtual VA system. Instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide a Veteran's claim for benefits. Because the current appeal was processed as part of the Virtual VA system, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The issue of entitlement to a nonservice-connected pension was previously referred to the Agency of Original Jurisdiction (AOJ) for appropriate action. A review of the claims file does not show that initial adjudication of that claim has been initiated. Therefore, the issue is again referred to the attention of the AOJ. FINDINGS OF FACT 1. Degenerative disc disease of the lumbar spine is not etiologically related to service. 2. Degenerative joint disease of the right knee was not diagnosed within one year of service, is not etiologically related to service, and is not proximately due to or aggravated by a service-connected condition. 3. Degenerative joint disease of the left knee was not diagnosed within one year of service, is not etiologically related to service, and is not proximately due to or aggravated by a service-connected condition. 4. Bilateral hearing loss was not diagnosed within one year of service, and is not etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. § 3.303 (2012). 2. The criteria for service connection for a right knee disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 3. The criteria for service connection for a left knee disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 4. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 A. Duty to Notify Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2012). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). Subsequent to the initial adjudication of the Veteran's claims, a letter dated in July 2012 was sent to the Veteran in accordance with the duty to notify provisions of the VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was notified of the evidence that was needed to substantiate his claim; what information and evidence that VA will seek to provide and what information and evidence the Veteran was expected to provide, and that VA would assist him in obtaining evidence, but that it was his responsibility to provide VA with any evidence pertaining to his claims. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). He was also notified of the criteria for establishing an effective date and disability rating. See Dingess. Here, the duty to notify was not satisfied prior to the initial decision on the Veteran's claims by the RO. Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence the VA found lacking in the claimant's presentation." Rather, such notice errors may instead be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the AOJ's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the AOJ) 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 a statement of the case (SOC) or supplemental statement of the case (SSOC), is sufficient to cure a timing defect). In this case, the VCAA duty to notify was satisfied subsequent to the initial AOJ decision by way of the July 2012 letter that addressed all notice elements, including the criteria for establishing service connection on a secondary basis, as well as the criteria for establishing a disability rating and effective date. Although the notice letter was not sent before the initial RO decision in this matter, the Board finds that this error was not prejudicial to the Veteran because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the Veteran been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond, but the claim was then readjudicated by way of an SSOC in April 2013, after the notice was provided. For these reasons, it is not prejudicial to the Veteran for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. See Shinseki v. Sanders/Simmons, 129 S.Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the United States Court of Appeals for Veterans Claims (Court) to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). B. Duty to Assist The Veteran's service treatment records, VA treatment records, private treatment records, and lay statements have been associated with the claims file. Pursuant to the Board's March 2013 remand, VA attempted to obtain the Veteran's Social Security Administration (SSA) records. However, correspondence from SSA dated March 2013 stated that it had no medical records in its possession. In April 2013, VA determined that further efforts to obtain any outstanding SSA records were futile. The Veteran was also afforded VA examinations. 38 C.F.R. § 3.159(c)(4). 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). The VA examinations obtained in this case are adequate as they are collectively predicated on a review of the claims file; contain a description of the history of the disabilities at issue; document and consider the relevant medical facts and principles; and provide opinions regarding the etiology of the Veteran's low back, bilateral knee, and hearing loss disabilities. VA's duty to assist with respect to obtaining a VA examination or opinion for the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board's March 2013 remand stated that RO/AMC should obtain the Veteran's SSA records and a supplemental opinion regarding the etiology of his hearing loss. As noted above, these directives have been completed. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Court or the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders). VA has provided the Veteran with the opportunity to submit evidence and argument in support of his claims. The Veteran has not made the Board aware of any additional evidence that needs to be obtained prior to appellate review, and no further action must be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Service Connection A. Applicable Law In order to establish service connection for a claimed disability, the facts must demonstrate that a disease or injury resulting in current disability was incurred in active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). In addition, certain chronic diseases, including arthritis and sensorineural hearing loss, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). For a showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. If the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). However, service connection based on a theory of continuity of symptomatology is applicable only for those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Arthritis and organic diseases of the nervous system (including sensorineural hearing loss) are listed as chronic conditions under 38 C.F.R. § 3.309(a). Therefore, service connection can be awarded for arthritis or sensorineural hearing loss if the evidence demonstrates continued symptomatology since service under 38 C.F.R. § 3.303(b). Arthritis and sensorineural hearing loss also may be presumed to have been incurred in service if they become manifest to a degree of 10 percent or more within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In addition to the applicable legal criteria cited above, service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2012). Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. A finding of secondary service connection requires competent medical evidence to connect the asserted secondary disability to the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Velez v. West, 10 Vet. App. 432 (1997). Effective October 10, 2006, 38 C.F.R. § 3.310 was amended in order to implement the holding in Allen v. Brown, 7 Vet. App. 439 (1995), regarding secondary service connection on the basis of the aggravation of a nonservice-connected disorder by a service-connected disability. See 71 Fed. Reg. 52744 (2006). The amended 38 C.F.R. § 3.310(b) institutes additional evidentiary requirements and hurdles that must be satisfied before aggravation may be conceded and service connection granted. In this regard, the recent amendment to 38 C.F.R. § 3.310 provides, in pertinent part, that 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 CFR 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. 38 C.F.R. § 3.310(b) (2012). Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in the line of duty. 38 U.S.C.A. § 101(21)(24); 38 C.F.R. § 3.6(a). Active military, naval, or air service also includes any period of inactive duty training (INACDUTRA) duty in which the individual concerned was disabled from injury incurred in the line of duty. Id. Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ACDUTRA or from injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1131. ACDUTRA includes full time duty performed by members of the National Guard of any state or the reservists. 38 C.F.R. § 3.6(c). INACDUTRA includes duty other than full time duty performed by a member of the Reserves or the National Guard of any state. 38 C.F.R. § 3.6(d). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza at 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). B. Low Back In various written statements, the Veteran contends that he injured his back during the Fall of 1953 during a parachute jump. He was treated by the medics at the drop zone and given medication on the spot. He was told that it was just a back sprain and that he would be fine in a day or two. However, he continued to experience back pain with long marches or prolonged standing. During his first period of leave, he sought treatment for his prolonged pain. He was given the same diagnosis and treated with muscle relaxers. This continued over the years until he eventually had to go to the hospital due to back pain. He underwent an MRI which revealed severe disc problems. Lay statements from the Veteran's family members support his contention of a back injury in 1953 or 1954 as a result of a parachute jump, and that the Veteran continued to have back problems after his separation from service. The Veteran underwent an enlistment examination in April 1953 and a September 1953 examination for airborne training. No relevant abnormalities were noted. During an August 1954 examination for helicopter school, the Veteran denied any history of back pain, and stated that his condition was excellent. Examinations in December 1955, November 1956 and October 1957 were normal. The Veteran denied any back-related complaints in October 1957 and again stated that his condition was excellent. A July 1958 separation noted no back problems, and the Veteran denied any complaints in the accompanying medical history report. In August 1958, the Veteran certified that there had been no change in his medical condition since his separation examination. An April 1976 entrance physical , and January 1977 and July 1978 flight status examinations, revealed no abnormalities, and the Veteran denied any history of recurrent back pain. In July 2005, the Veteran reported low back pain while riding a lawnmower. Private records show the Veteran was diagnosed with lumbar degenerative disc disease in January 2008. The Veteran underwent a VA examination in February 2010. The claims file was reviewed by the examiner, who noted the Veteran's contention that he injured his back following a parachute jump in 1953, and that he had experienced intermittent back pain since his separation from service without any specific re-injury. Based on a review of the claims file, a history provided by the Veteran, and an examination, the examiner diagnosed severe degenerative disc disease of the lumbar spine. However, this condition was less likely than not related to service. There was no documentation of treatment for a lower back condition during active service, and there was no recurrent treatment for back pain for 45 years after service. An additional opinion was obtained in July 2012. Although the Veteran reported injuring his back in service, and being seen by a chiropractor for 10 years after his separation, the examiner noted that there are no records pertinent to a back condition available in the claims file until July 2005. The examiner further noted that the Veteran worked as a helicopter pilot during service and for 27 years as a civilian. Pilots were subject to multiple repeated load-bearing stresses on the moveable parts of the spine, and it is not uncommon for career pilots to develop multilevel degenerative disc disease of the cervical and lumbar spines. However, there was no available documentation of problems with the Veteran's back during active or reserve service. He was first documented treatment was 50 years after his active service, and 25 years after his reserve service. The examiner again reiterated that the Veteran's back condition was less likely than not related to service. Based on the evidence of record, the Board finds that service connection for a low back disability is not warranted. Although the Veteran is diagnosed with degenerative disc disease of the lumbar spine, the overall weight of the evidence is against a finding that this condition was incurred in or otherwise related to service. While the Veteran reported a 1953 back injury and subsequent pain, service treatment records do not document any complaints, treatment, or diagnoses of a back condition. The Veteran underwent multiple examinations after his alleged injury, and no relevant abnormalities were noted. The earliest documented finding of a back condition is from July 2005, 52 years after the Veteran's claimed back injury in service. The VA examiner in this case concluded that the Veteran's current condition was not related to service. This opinion was based on a review of the claims file, a history provided by the Veteran, and a physical examination, and is supported by an appropriate rationale. There is no competent medical opinion to refute this conclusion or to otherwise suggest that the Veteran has a back condition related to service. The Board has considered the Veteran's own statements, and those of his family members, made in support of his claim. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, degenerative disc disease and spinal stenosis fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Therefore, these lay statements are not considered competent medical evidence and do not establish a medical nexus between the Veteran's current condition and service. Further, to the extent that the Veteran's lay statements are offered as evidence of continuity of symptomatology, the Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). As noted, in adjudicating his claims, the Board must evaluate the Veteran's credibility. See Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. The Veteran and other lay witnesses are competent to provide evidence of their own experiences. It is also consistent with the Veteran's service and his receipt of the Parachute Badge that he would suffer injury to the back. However, the Veteran underwent numerous examinations as part of his active and reserve service, and no relevant abnormalities were recorded during those examinations. In fact, the Veteran consistently reported his condition as normal and did not report any history of back pain or other symptoms. Finally, while the Veteran reported during his VA examinations that he had experienced ongoing back pain since service, his outpatient records do not include any similar reports. These facts weigh heavily against the claim he now makes that he has had problems ever since service and undermine his credibility, in this regard. The Board is not holding that corroboration is required. Rather, the Board finds the assertions of continuous symptoms since service to be less credible than the negative contemporaneous records. The Board notes that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. However, with respect to a merits review, the lack of evidence of treatment may bear on the credibility of the evidence of continuity. As such, the Board finds that the probative evidence is against the claim based on continuity of symptomatology. The Court has indicated that the normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for the pertinent chronic disability for many years after service, is probative evidence against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). C. Right Knee In various written statements, the Veteran contends that he injured his right knee as a result of marching and parachute jumps in service. He also reported that he injured it after stepping in a trench during the Fall of 1953. The Veteran underwent an enlistment examination in April 1953. No relevant abnormalities were noted. Records dated August 1953, and a subsequent September 1953 examination for airborne training, noted that the Veteran complained of right knee pain. X-rays did not reveal any bone or joint abnormality. During an August 1954 examination for helicopter school, the Veteran denied any history of a "trick" or locked knee. Examinations in December 1955, November 1956 and October 1957 were normal. The Veteran denied any knee-related complaints in October 1957 and again stated that his condition was excellent. A July 1958 separation examination noted that the right knee joint was stable, with no pain or locking elicited. A separate notation indicated that the Veteran had experienced right knee pain after a long march over broken ground 4 years ago, but had no difficulty since then. In August 1958, the Veteran certified that there had been no change in his medical condition since his separation examination. An April 1976 entrance physical and January 1977 flight status examination revealed no abnormalities. In May 1978, the Veteran reported twisting his knee while playing volleyball. X-rays were normal, and he was diagnosed with right knee strain. A July 1978 flight status examination revealed no abnormalities, and the Veteran denied any history of knee problems. Private records dated October 1987 show a diagnosis of moderate degenerative joint disease in the right knee. Additional records dated May 1990 also show diagnoses of chondromalacia and a torn meniscus. The Veteran underwent a total knee arthroplasty in August 1993. Subsequent records show ongoing right knee complaints. A VA examination was conducted in February 2010. The claims file was reviewed by the examiner, who noted the Veteran's documented complaints of right knee pain in 1953 and 1978. The Veteran was unable to clarify an exact time frame or onset date for his knee problems, but stated that he had significant problems with his right knee up until 1985 when he sought treatment. Based on a review of the claims file, a history provided by the Veteran, and an examination, the examiner diagnosed severe degenerative arthritis of the right knee, status post total knee arthroplasty and multiple revision surgeries. However, she concluded that this condition was less likely than not related to service. Although the Veteran had a documented episode of right knee pain, his subsequent separation examination noted that the Veteran was asymptomatic, with no pain, locking, or instability in the knee. Although there was a report of a twisting injury in 1978, this was well after his period of active duty. It was more likely that his condition was due to the natural pathophysiological process of aging in a somewhat heavyset individual who had a physically demanding job for most of his adult career. A supplemental opinion was obtained in July 2012. The examiner again noted that while the Veteran had documented right knee pain in 1953, his subsequent examinations were normal with no sequelae. Although a right knee injury occurred in May 1978, a July 1978 examination revealed no right knee symptoms or complaints. There were no additional knee complaints for many years after. The examiner further noted that the Veteran worked as a helicopter pilot for 27 years after service, and also worked as a construction manager. Although records from 1991 reflect findings of "internal derangement for many years," the number of years was not specified. However, his left total knee replacement was 5 years before his right knee replacement. The examiner thus found that it would be reasonable to expect that the more severe left knee symptoms caused prolonged increased weight-bearing on the right knee, eventually worsening the degenerative process. Therefore, the examiner determined that although the Veteran is claiming that his right knee condition was due to service, he had more severe left knee symptoms prior to right knee symptoms, and his right knee problems were more likely due to the pathophysiologic aging process and increased weight-bearing from his left knee problems. Based on the evidence of record, the Board finds that service connection for a right knee disability is not warranted. Although the Veteran is diagnosed with degenerative joint disease of the right knee, the overall weight of the evidence is against a finding that this condition was incurred in or otherwise related to service. While the Veteran reported right knee pain in August of 1953, there were no associated objective findings. The Veteran also underwent multiple examinations after his alleged injury, and no relevant abnormalities were noted. He again reported a right knee injury in May 1978, but again, a subsequent examination noted normal findings. The VA examiner in this case ultimately concluded that the Veteran's current condition was not related to service. This opinion was based on a review of the claims file, a history provided by the Veteran, and a physical examination, and is supported by an appropriate rationale. There is no competent medical opinion to refute this conclusion or to otherwise suggest that the Veteran has a right knee condition related to service. Additionally, as the first finding of degenerative joint disease of the right knee was not shown to be diagnosed within one year of the Veteran's discharge from active duty service, service connection on a presumptive basis is not warranted. See 38 C.F.R. §§ 3.307, 3.309. The Board has again considered the Veteran's own statements made in support of his claim. However, as to the specific issue in this case, degenerative joint disease falls outside the realm of common knowledge of a lay person. See Jandreau. Therefore, these lay statements are not considered competent medical evidence and do not establish a medical nexus between the Veteran's current condition and service. With respect to any contentions of continuous right knee symptoms, the Veteran is competent to report that he experienced knee pain in service. The Veteran's reports are consistent with the service treatment records documenting injury to the knee in service. Also, it is consistent with the Veteran's service and his receipt of the Parachute Badge that he would suffer injury to the knees. Additionally the Veteran was noted as having injured his right knee in May 1978 during National Guard service. However, the Veteran underwent numerous examinations as part of his active and reserve service, and he denied having any right knee symptoms on multiple occasions. These facts weigh heavily against the claim he now makes that he has had problems ever since service, and undermine his credibility, in this regard. Again, corroboration is not required, but rather the Board finds the assertions of continuous symptoms since service to be less credible than the negative contemporaneous records. To the extent that the Veteran has asserted that he has a right knee disability secondary to his low back disability, service connection for the low back has not been established. Therefore, service connection for the right knee on a secondary basis is not appropriate. D. Left Knee In various written statements, the Veteran contends that he injured his left knee as a result of marching and parachute jumps in service. The Veteran underwent an enlistment examination in April 1953. No relevant abnormalities were noted. During a September 1953 examination for airborne training, the Veteran complained of right knee pain, but no left knee abnormality was noted. During an August 1954 examination for helicopter school, the Veteran denied any history of a "trick" or locked knee. Examinations in December 1955, November 1956 and October 1957 were normal. The Veteran denied any knee-related complaints in October 1957 and again stated that his condition was excellent. A July 1958 separation noted no left knee problems, and the Veteran denied any complaints in the accompanying medical history report. In August 1958, the Veteran certified that there had been no change in his medical condition since his separation examination. An April 1976 entrance physical, and January 1977 and July 1978 flight status examinations revealed no abnormalities, and the Veteran denied any history of knee problems. Private records dated October 1987 show the Veteran was diagnosed with degenerative joint disease in his left knee, and he underwent a total knee arthroplasty. He reported that his condition had become severe in the past 16 or 18 months. Subsequent records show ongoing complaints associated with the left knee. The Veteran underwent a VA examination in February 2010. He reported the onset of left knee pain in the mid-1980's without specific trauma. He was working as a construction manager and began having difficulty doing the activities required by his occupation. He sought treatment and was told he had arthritic changes in his knee. Based on a review of the claims file, a history provided by the Veteran, and an examination, the examiner diagnosed severe degenerative arthritis, status post total knee arthroplasty and multiple revision surgeries. However, she stated that this condition was less likely than not related to service. The Veteran's reported onset of left knee pain was around 1985, almost 30 years after leaving active service. The examiner determined that the Veteran's condition was more likely due to the natural pathophysiologic process of aging in a somewhat heavy set individual who had fairly physically demanding jobs during his adult career. It was further noted that the Veteran would have been expected to have ongoing problems with the left knee requiring medical intervention earlier than 1985 if his knee had been significantly injured by parachute jumping in service. Based on the evidence of record, the Board finds that service connection for a left knee disability is not warranted. Although the Veteran is diagnosed with degenerative joint disease of the left knee, the overall weight of the evidence is against a finding that this condition was incurred in or otherwise related to service. Service treatment records contain no findings relating to a left knee condition, and the Veteran himself stated that the onset date for his symptoms was in the mid-1980's, well after his period of service. The VA examiner in this case concluded that the Veteran's current condition was not related to service. This opinion was based on a review of the claims file, a history provided by the Veteran, and a physical examination, and is supported by an appropriate rationale. There is no competent medical opinion to refute this conclusion or to otherwise suggest that the Veteran has a left knee condition related to service. Additionally, as the first finding of degenerative joint disease of the left knee was not shown to be diagnosed within one year of the Veteran's discharge from active duty service, service connection on a presumptive basis is not warranted. See 38 C.F.R. §§ 3.307, 3.309. The Board has again considered the Veteran's own statements made in support of his claim. However, as to the specific issue in this case, degenerative joint disease falls outside the realm of common knowledge of a lay person. See Jandreau. Therefore, these lay statements are not considered competent medical evidence and do not establish a medical nexus between the Veteran's current condition and service. The Veteran has also not asserted that he had experienced continuous left knee symptomatology since his discharge from service. E. Hearing Loss The Veteran contends that he sustained bilateral hearing loss as a result of noise exposure in service, to include exposure to airplanes and helicopters. A December 2012 VA examination report notes that the Veteran stated that he was a helicopter pilot in the Army from 1953 to 1958. He also was a helicopter pilot for 20 years as a civilian after the military, and used to hunt. Impaired hearing will be considered a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; or the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2012). Section 3.385 of Title 38, Code of Federal Regulations does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). When audiometric test results at the veteran's separation from service do not meet the regulatory requirements for establishing a "disability" at that time, a veteran may nevertheless establish service connection for a current hearing disability by submitting competent evidence that the current disability is causally related to service. Id. at 160. The threshold for normal hearing is zero decibels to 20 decibels and higher threshold levels indicate some degree of hearing loss. Id. at 157. Prior to November 1967, audiometric results in service department records were reported in standards set forth by the American Standards Association (ASA). Those are the figures on the left in each column and are not in parentheses. Since November 1, 1967, those standards have been set by the International Standards Organization (ISO)-American National Standards Institute (ANSI). In order to facilitate data comparison, the ASA standards have been converted to ISO-ANSI standards and are represented by the figures in parentheses. During the Veteran's April 1953 and July 1958 examinations, hearing was 15/15 on whispered voice testing. During the Veteran's August 1954 examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 ISO add (+15) (+10) (+10) (+10) (+5) RIGHT 5 (20) 0 (10) 0 (10) Not tested 0 (5) LEFT -5 (10) 0 (10) 0 (10) Not tested 0 (5) In December 1955, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 ISO add (+15) (+10) (+10) (+10) (+5) RIGHT 15 (30) 10 (20) 15 (25) Not tested 15 (20) LEFT 10 (25) 5 (15) 10 (20) Not tested 10 (15) The Veteran complained in April 1956 that he could not hear out of his right ear. He was found to have cerumen in both ears, which was irrigated, but the pain in the right ear persisted and the umbra was red. However, he was cleared for flying as the ear was easily aerated. On examination in April 1976, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 5 5 LEFT 5 5 25 30 35 On examination in January 1977, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 0 5 10 LEFT 5 0 20 15 10 The examiner noted that the Veteran's hearing loss was within Class II limits and the Veteran was qualified for Class II flight. On examination in July 1978, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 0 20 25 LEFT 20 25 20 25 20 The Veteran noted a history of inner ear infection in 1954 with no problems. After service, the Veteran was afforded a VA audiological examination in February 2010; however, the examiner stated that the results provided by the Veteran did not seem to correlate to his abilities in everyday conversations. Therefore, tests were repeated and variability of responses was found. Additionally, discrepancies on the examination indicated that the Veteran's responses reflected a lack of cooperation with test procedures. The examiner stated that the Veteran was pleasant, but, due to his lack of cooperation, his responses were not to be considered reliable and an opinion could not be provided due to the lack of valid responses. A July 2010 private audiogram is also of record, which supports a diagnosis of hearing loss under 38 C.F.R. § 3.385, with decibel losses higher than 40 dB at 2000 and 4000 Hz. With respect to the speech recognition scores, however, there is no indication that Maryland CNC testing was performed. VA treatment records dated November 2011 reflect bilateral hearing loss as defined by 38 C.F.R. § 3.385. An additional VA examination was conducted in December 2012. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 15 20 35 55 LEFT 25 25 45 65 70 Speech audiometry revealed speech recognition ability of 86 percent in the right ear and of 76 percent in the left ear. The examiner stated that pure tone thresholds and speech recognition scores were valid and appropriate. Based on a review of the claims file, a history provided by the Veteran, and an examination, the examiner diagnosed bilateral sensorineural hearing loss. However, he concluded that this condition was less likely than not related to service. This was based on the fact that the Veteran had multiple hearing tests after active duty which revealed normal hearing thresholds. In an April 2013 opinion, the VA examiner further clarified that a comparison of the Veteran's first hearing thresholds in 1954 with his latest service evaluation in 1978 reflect some shift in thresholds, suggesting some decrease in hearing acuity. However, current studies, such as the 2006 Institute of Medicine study, do not support the concept of delayed onset hearing loss due to noise exposure. Therefore, current hearing loss was less likely than not related to service. Based on the evidence of record, service connection for bilateral hearing loss is not warranted. Although the Veteran is currently diagnosed with the condition, the overall weight of the evidence is against a finding that it was incurred in or otherwise related to service. Because the Veteran engaged in airborne training and served as a helicopter pilot in service, his allegations of military noise exposure are conceded. Moreover, pure tone thresholds from service do reflect some thresholds in excess of 20 db, indicative of some hearing loss. See Hensley. However, there are no actual diagnoses of hearing loss, and the pure tone thresholds in service do not meet the criteria of 38 C.F.R. § 3.385 for hearing loss. The Veteran did not report any complaints of hearing loss at any time during service, other than complaints of right ear hearing loss when he had an ear infection. The VA examiner in this case concluded that the Veteran's current condition was not related to service, even when accounting for the shifts in pure tone thresholds that occurred during service. While the examiner cited to studies as part of the basis for the opinion that the hearing loss was not related to service, the examiner also considered in the previous examination in December 2012 that the Veteran had multiple hearing tests after active duty which revealed normal hearing thresholds. The examiner had previously determined this and then when providing the supplemental opinion in April 2013, added that the 2006 Institute of Medicine study did not support the concept of delayed onset hearing loss due to noise exposure. Statistical analysis can be a factor to consider when assessing whether the totality of the evidence is sufficient to establish direct service connection, even when the statistical analysis alone would be insufficient. Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009). The December 2012 and April 2013 opinions were based on a review of the claims file, a history provided by the Veteran, and a physical examination, and are supported by an appropriate rationale. There is no competent medical opinion to refute this conclusion or to otherwise suggest that the Veteran has bilateral hearing loss related to service. Also, as the first finding of hearing loss for VA purposes was not within one year of discharge from service, entitlement to service connection on a presumptive basis is not warranted. See 38 C.F.R. §§ 3.307, 3.309. The Board acknowledges that the Veteran is competent to report that he has continued to experience hearing loss since service since service. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). The Veteran is also competent to report that he was exposed to acoustic trauma in service. See Washington v. Nicholson, 19 Vet. App. 362 (2005) (holding that a Veteran is competent to report what occurred during service because he is competent to testify as to factual matters of which he has first-hand knowledge). Competent testimony is limited to that which the witness has actually observed and is within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses-that which is heard, felt, seen, smelled, or tasted. Layno v. Brown, 6 Vet. App. 465 (1994). It is within the Veteran's realm of personal knowledge whether he had exposure to loud noises in service, and has continued to experience hearing loss since that time. The Veteran served in the Army as a helicopter pilot; thus, it is reasonable to deduce that he would have been exposed to noise from these duties. His service treatment records are also internally consistent as they show changes in hearing thresholds and some hearing loss in service. However, there is no actual statement from the Veteran that he has continued to experience hearing loss since service. Also, any statements to that effect would not be credible, as they would be inconsistent with the audiograms that were performed after the Veteran's active duty in the 1970s, which showed normal hearing. Therefore, with respect to the onset of experiencing hearing loss, the Veteran's lay assertions do not provide any significant probative value. In addition, even if the Veteran had argued that his hearing loss started in service and continued thereafter, it does not follow that any present hearing loss is necessarily related to any demonstrated continuous symptomatology. While the Veteran is competent to state that he has suffered from symptomatology in his ears since service, he is not competent to determine the underlying cause of the symptoms, i.e., hearing loss disability, etc. The service treatment records also note complaints of a right ear infection and hearing loss in the right ear at the time of this infection. In addition the Board finds it significant that the Veteran was a helicopter pilot for 20 years after service as a civilian, and also hunted. The Veteran contends that his current hearing loss is related to his exposure to acoustic trauma in service; however, there is no competent medical evidence or opinion to corroborate these contentions. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements, or opinions). The Veteran's opinions are insufficient to provide the requisite nexus between an in-service event or injury and any current disability because, as a lay person, he is not competent to establish a medical etiology merely by his own assertions; such matters require medical expertise. See 38 C.F.R. § 3.159(a)(1); Duenas v. Principi, 18 Vet. App. 512, 520 (2004); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) (holding that a layperson is generally not capable of providing opinions on matters requiring medical knowledge, such as the condition causing or aggravating the symptoms); see also Bostain v. West, 11 Vet. App. 124, 127 (1998); Stadin v. Brown, 8 Vet. App. 280, 284 (1995); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). As such, his statements regarding the etiology of any hearing loss disability are merely speculation as to a possible cause as he is not medically qualified to prove a matter requiring medical expertise, such as an opinion as to medical causation. The Board also finds it significant that a VA examiner in December 2012 and April 2013 found that after reviewing the claims file and pertinent medical history that the Veteran's hearing loss was not related to acoustic trauma in military service, because, notwithstanding the shifts in auditory thresholds in service and exposure to noise trauma, the Veteran had normal hearing exams in the intervening years after service. The probative value of the VA examiner's opinion is high as the examiner was fully informed of the Veteran's medical history, provided a fully articulated rationale, and the opinion was supported by a reasoned analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). As such, after weighing and balancing the evidence of record, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran's current hearing loss had its onset during active service or are related to any in-service disease, event, or injury. See 38 U.S.C.A. §§ 1110, 1131. Accordingly, the Board finds that the criteria for service connection for hearing loss are not met and the Veteran's claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b). However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). ORDER Service connection for a low back disability is denied. Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. Service connection for bilateral hearing loss is denied. ____________________________________________ SARAH B. RICHMOND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs