Citation Nr: 1321737 Decision Date: 07/08/13 Archive Date: 07/18/13 DOCKET NO. 07-20 661 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a right knee disability, as secondary to service-connected lumbar post laminectomy syndrome with lumbar degenerative disease as well as recurring fibroma of the left foot. 2. Entitlement to service connection for a left knee disability, as secondary to service-connected lumbar post laminectomy syndrome with lumbar degenerative disease as well as recurring fibroma of the left foot. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Saira Spicknall, Counsel INTRODUCTION The Veteran served on active duty from October 1962 to July 1963. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2006 rating decision of the St. Petersburg, Florida Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing at the RO before the undersigned Veterans Law Judge of the Board (Travel Board hearing) in May 2009. A transcript of that hearing has been associated with the claims file. This case was previously remanded by the Board in October 2009 and August 2011 for additional development. A review of the Virtual VA paperless claims processing system reflects that additional records have been added to the present appeal. These records include VA medical records. The Board is aware that the most recent supplemental statement of the case (SSOC) was issued in July 2013 and did not address this evidence. As discussed below, the Board finds that issuance of an SSOC addressing this additional medical evidence is not prejudicial to the claim as the evidence is essentially cumulative of previous evidence in the claims file. See 38 C.F.R. § 20.1102 (2012). FINDINGS OF FACT 1. The preponderance of the evidence demonstrates that a right knee disability did not originate in service, is not related to any incident during active service, and is not caused or aggravated by any service-connected disabilities. 2. The preponderance of the evidence demonstrates that a left knee disability did not originate in service, is not related to any incident during active service, and is not caused or aggravated by any service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for the establishment of service connection for a right knee disability, as secondary to service-connected lumbar post laminectomy syndrome with lumbar degenerative disease as well as recurring fibroma of the left foot, have not been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. The criteria for the establishment of service connection for a left knee disability, as secondary to service-connected lumbar post laminectomy syndrome with lumbar degenerative disease as well as recurring fibroma of the left foot, have not been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act (VCAA) The VCAA, codified, in part, at 38 U.S.C.A. § 5103, was signed into law on November 9, 2000. Implementing regulations were created, codified at 38 C.F.R. § 3.159 (2012). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012). The United States Court of Appeals for Veterans Claims (Court) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a) (West 2002), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Prior to the initial adjudication of the Veteran's claims for service connection in the June 2006 rating decision, he was provided notice of the VCAA in October 2005. The VCAA letter indicated the types of information and evidence necessary to substantiate a claim for secondary service connection (as the Veteran has not claimed direct service connection), and the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. The Veteran also received notice in September 2006 and April 2009, pertaining to the downstream disability rating and effective date elements of his claims, and was furnished a statement of the case in May 2007 with subsequent re-adjudication in July 2008 January 2011 and July 2012 SSOCs. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also Mayfield and Pelegrini, both supra. All relevant evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, to the extent possible. The evidence of record includes service treatment records, Social Security Administration (SSA) records, private medical records, VA outpatient treatment reports, adequate VA examinations and statements and testimony from the Veteran and his representative. The Board notes that the April 2010 and September 2011 VA examination reports, taken together, reflect that the examiners reviewed the Veteran's past medical history, documented his current medical condition, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record, and with supporting rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board observes that while the April 2010 VA examination did not provide a rationale for the opinion regarding aggravation of the Veteran's bilateral knee disability and this part of the opinion is inadequate, the examiner's opinion regarding causality is adequate and supported by an adequate rationale. Consequently, the Board concludes that the medical examinations and opinions, except the April 2010 opinion addressing aggravation, taken together, are adequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The Board observes that, in the September 2011 VA examination, the examiner found that, with regard to the Veteran's altered gait and whether it was due to his low back or left foot fibroma, he could not resolve that issue without resorting to speculation. The examiner explained in his rationale that the previous orthopedic examination and opinion noted that the claimed limping was not caused by the fibroma of the left foot. He also noted that the current clinical findings could not support a causality of the claimed bilateral knee osteoarthritis and disability to his fibroma of the left foot and low back condition. The examiner found that there was no knowledge in medical literature that would support this causality. He also noted the physical examination showed stable cruciates and collaterals with no swelling, induration, ecchymosis or effusion and there was no atrophy of the quadriceps, hamstrings, gastrocnemius solus or peroneal muscle. He noted there was no leg length discrepancy. The examiner found that it was impossible to determine in the altered gait was due to his left foot or low back disability. In this case, the Board finds that the September 2011 opinion regarding the Veteran's altered gait and whether it was due to his low back or left foot fibroma, is adequate. In this regard the Board points to Jones v. Shinseki, in which the Court determined that an "examination is not inadequate merely because the examiner states he or she cannot reach a conclusion without resort to speculation." Jones, 23 Vet. App. at 391. The Court also found that "VA is not bound to proceed through multiple iterations of medical opinions until it declares that no further examinations would assist the claimant[,]" which, in the Court's view, was "inherent in a finding that the duty to assist has been fulfilled." Id. In Jones, the Court notes that the duty to assist requires VA to obtain all relevant information that may reasonably be obtained before the Board may rely on a VA medical examiner's opinion to deny a claim and enumerates the steps under which the duty to assist may apply. Id. at 388. The Court first finds that the duty to assist applies when "an examiner specifically identifies additional information that would facilitate a more conclusive opinion." In this case, the Board finds that, the examiner did not specify that any additional information would be necessary to facilitate a more conclusive opinion in the September 2011 VA examination report. The Court then found that "it must be clear on the record that the inability to opine on questions of diagnosis and etiology is not the first impression of an uninformed examiner, but rather an assessment arrived at after all due diligence in seeking relevant medical information that may have bearing on the requested opinion." Id. at 389. The Board observes that the VA examiner in the September 2011 VA examination based his conclusions upon a review of the claims file, the Veteran's reported history and an examination of the Veteran. As such, his conclusions were based upon due diligence and relevant medical information that may have had a bearing on the case in reviewing the claims file. Thereafter, the Court in Jones found that, while an opinion that diagnosis or etiology was not possible without resorting to speculation was just as much a medical conclusion as a firm diagnosis or a conclusive opinion, a bald statement that it would be speculative to render an opinion as to etiology or diagnosis was ambiguous and thus, it must be clear, that the examiner has considered "all procurable and assembled data," by obtaining all relevant tests and records that might reasonably illuminate the medical analysis. Id. at 390. Thus, only when this issue is in doubt does the Board's duty to remand for further development arise. In this case, it is clear that that the examiner considered all procurable and assembled data, including, the available service records, documentation of injuries and treatment to the Veteran's back, knees and left foot, the Veteran's reported history, the available post-service records and a physical examination of the Veteran in rendering the September 2011 VA examination opinion. Moreover, the examiner made it clear that his opinion reflected the limitations of knowledge in the medical community at large, by noting that there was no knowledge in medical literature that would support this causality. See id. Finally, the examiner clearly identified precisely what facts could not be determined; in this case, he specified that it was impossible to determine the altered gait was due to his left foot or low back disability, that the physical examination showed stable cruciates and collaterals with no swelling, induration, ecchymosis or effusion and there was no atrophy of the quadriceps, hamstrings, gastrocnemius solus or peroneal muscle, and that there was no knowledge in medical literature that would support this causality. See id. Accordingly, in this case it would be inappropriate for VA to demand a conclusive opinion from a physician whose evaluation of the "procurable and assembled" information prevents the rendering of such an opinion and it is otherwise apparent, based on the Board's review of the evidence, that there is nothing further to be obtained from that particular examiner. See id. at 391. While the duty to assist the veteran includes providing a medical examination in certain situations, that duty does not extend to requiring a VA physician to render an opinion beyond what may reasonably be concluded from the procurable medical evidence. See id. Therefore, based upon the foregoing, the Board finds that the September 2011 VA examination and opinion were adequate. This case was previously remanded by the Board in August 2011 to provide the Veteran with an adequate VA opinion. As the September 2011 VA examiner provided an adequate opinion and complied with the Board's remand instructions, the Board is satisfied that the development requested by its August 2011 remand has now been satisfactorily completed and substantially complied with respect to the Veteran's bilateral knee disabilities on appeal. See Stegall, 11 Vet. App. 268 (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). In May 2009 the Veteran was afforded a Travel Board hearing before the undersigned. The transcript reflects that the Veterans Law Judge conducted the hearing in accordance with the statutory duties to "explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position," pursuant to 38 C.F.R. § 3.103(c)(2), as explained by the Court in Bryant v. Shinseki, 23 Vet. App. 488 (2010). The transcript of the hearing reflects that the Veterans Law Judge identified the material issues-entitlement to a service connection for osteoarthritis of the right and left knee as secondary to the low back and left foot disabilities. The Veterans Law Judge also noted the current disabilities of the low back and left foot were service-connected. She asked whether any physician had related the Veteran's bilateral knee disabilities to his low back or left foot, which the outcome of the case ultimately turns upon. On subsequent remand, the Veteran was provided the opportunity to submit supplemental private medical opinions with rationale, among other things. Thus, the Board finds that the hearing officer's duties in 38 C.F.R. § 3.103(c)(2) were met and that the Veteran was not prejudiced by the hearing that was provided. See Bryant, 23 Vet. App. at 498 (citing to 38 U.S.C. § 7261(b)(2); Shinseki v. Sanders, 129 S. Ct. 1696, 1704 (2009)). The May 2009 hearing was legally sufficient. Moreover, any deficiencies in the Board hearing under section 3.103(c)(2) were not prejudicial. Specifically, VA has otherwise developed this claim, including providing several VA examinations and obtaining medical opinions which directly address the outstanding issues, as discussed above with regard to VA's duty to assist under the VCAA. The Veteran has also submitted opinions by private physicians and witness statements. Again, he was provided the opportunity to submit supplemental private medical opinions with rationale. Thus, in light of the information and evidence already of record, including that submitted by the Veteran, there is no indication of any outstanding evidence that may have been overlooked. See id. at 499. A review of the Virtual VA paperless claims processing system reflects that additional records have been added to the present appeal. These records include VA medical records. The Board is aware that the most recent SSOC was issued in July 2013 and did not address this evidence. Under the current regulations, 38 C.F.R. § 20.1304 provides that any "pertinent" evidence submitted by the Veteran which is accepted by the Board must be referred to the agency of original jurisdiction (AOJ) for review, unless this procedural right is waived by the Veteran. No such waiver was received in this instance. However, upon review of the evidence, the Board finds that it is essentially cumulative of evidence of record previously associated with the claims filed. In this regard, the evidence consists of VA medical records reflecting a complaint of right knee pain in July 2010. The Board observes that the claims file already documents the Veteran's treatment for bilateral knee pain and diagnoses for the left and right knees. Therefore, the Board finds that the evidence is essentially cumulative in nature and amounts to a repeat of documents already of record. In any event, for the reasons discussed above, the Board determines that the provisions of 38 C.F.R. § 20.1304 are inapplicable in this case and that any error in not returning the claims to the AOJ for readjudication is harmless and results in no prejudice to the Veteran. See 38 C.F.R. §§ 20.1102, 20.1304 (2012). The Veteran has not indicated that he has any further evidence to submit to VA, or which VA needs to obtain. There is no indication that there exists any additional evidence that has a bearing on this case that has not been obtained. The Veteran and his representative have been accorded ample opportunity to present evidence and argument in support of his appeal. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2012). Pertinent Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for a claimed disorder on a direct basis, there must be: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of the in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service connected disease or injury; or, for any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progression of the nonservice-connected disease. 38 C.F.R. § 3.310(a)-(b); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The determination as to whether the requirements for service connection are met is based on an analysis of all of the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a) (West 2002); 38 C.F.R. § 3.303(a) (2012). See Baldwin v. West, 13 Vet. App. 1 (1999). When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). See Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). If the Board determines that the preponderance of the evidence is against the claim, then it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule will not be applicable. Ortiz, 274 F.3d at 1365. With regard to VA examinations, the Board notes that the most recent examination is not necessarily and always controlling; rather, consideration is given not only to the evidence as a whole but to both the recency and adequacy of examinations. See Powell v. West, 13 Vet. App. 31, 35 (1999). Analysis The Veteran contends that his service-connected low back and left foot disabilities resulted in his limp, which was the source of his bilateral knee disabilities. Service treatment reports are absent of any complaints or findings related to the bilateral knees. In the February 1962 Report of Medical History, the Veteran did not report a history of problems with the knees. The July 1963 separation examination revealed no abnormalities of the lower extremities upon clinical evaluation. SSA records reflect that the Veteran was awarded SSA disability benefits for his low back disability in a June 1993 decision. VA medical records from August 1964 to October 1977 and from March 1997 to February 2013 as well as private medical records from October 1991 to August 2008 reflect that the Veteran was initially treated for complaints of right knee pain in April 2004 by a private physician. In an April 2004 letter, the Veteran's private treating physician at that time, Dr. P.J.A., reported that the Veteran was seen in April 2004 for right knee pain and noted that he had ongoing left foot problems status post surgery. He concluded that it was likely the Veteran's ongoing foot problems were contributing to his knee strain. An April 2004 private x-ray of the right knee revealed no radiographically demonstrable abnormalities of the right knee. A June 2005 VA x-ray of the bilateral knees revealed findings suggestive of early osteoarthritis with some decrease joint space and calcification in cartilaginous structures in the medial compartments of both knees. In August 2005 and September 2005 VA outpatient treatment reports, the Veteran complained of right knee pain and reported an 18 month history of pain in the right knee, attributed his limping to his knee pain and denied any specific injury to the knee. In September 2005 and November 2005 VA outpatient treatment reports, the Veteran reportedly believed his foot problem contributed to his knee problems. Subsequent VA and private medical records reflect the Veteran was variously treated for and diagnosed with bilateral knee pain and bilateral mild degenerative joint disease of the knees. In a February 2006 VA opinion, a VA examiner noted that the Veteran's diagnosis for his knee condition was early osteoarthritis with decreased joint space and some calcifications in the menisci reminiscent of pseudo gout, in the medial compartments of both knees. He found that the Veteran had pseudogout or chondrocalcinosis or arthritis that produced calcific deposition in the menisci and that etiology of this was usually on a degenerative arthritic basis. The examiner did not feel that the knee abnormality was correlated or causally produced by the pathology that the Veteran had in his foot. He did not think there was any indication or any literature that would support that phenomena. The examiner noted the Veteran's cruciates and collaterals were stable and he had no swelling, induration, ecchymosis or effusion. He also noted that there was no muscle atrophy of the quadriceps, hamstrings, gastrocnemius solus or peroneal. An April 2007 private magnetic resonance imaging (MRI) of the right knee revealed prominent linear signal within the body and posterior horn of the medial meniscus with extension through the radial edge, which may be related to postoperative change secondary to prior partial meniscectomy, although residual recurrent tear was not excluded. This MRI also demonstrated findings of mild proximal patellar tendinosis, slightly worsened from previous examination, stable ganglion cyst adjacent to popliteus myotendinous junction and well preserved articular cartilage. An April 2007 private MRI of the left knee revealed mildly complex, nondisplaced tear of the posterior horn of the medial meniscus, mild patellar tendinosis proximally, ganglion cyst adjacent to the popliteus myotendinous junction, and proximal fibulo-collateral ligament mucoid degeneration. A June 2007 private medical report reflects findings indicating the Veteran ambulated at normal pace with a slight limp on the left lower extremity. In a June 2007 letter, the Veteran's private podiatrist , Dr. J.H., DPM, reported that the Veteran presented in her office in April 2007 with pain in the left foot and ankle for many years. She stated that the Veteran reported that he was unable to walk properly due to the pain in the bottom of the foot and had been using a cane since 2004. He believed the foot pain was contributing to his knee and back pain. She stated the Veteran was placed in a walking cast for five weeks and reevaluated in June and began physical therapy then. She found that the Veteran continued to have long term pain secondary to scar formation on the bottom of the left foot and noted that this may be contributing to an impaired gait. The Veteran underwent a meniscectomy of the right knee in October 2006 and a meniscectomy of the left knee in August 2007 by a private physician, per a September 2007 private medical record. In a December 2007 VA examination of the knees, the Veteran reported having an onset of bilateral knee pain in 2004 and stated that his right and left knee conditions were secondary to his left foot fibroma. He denied any trauma to the knees and had no idea how the right and left meniscus were injured. The Veteran complained of constant knee pain for which he took medication for relief. The Veteran's history of an arthroscopy and partial meniscus removal in the right knee in October 2006 and an arthroscopy and partial meniscus removal in the left knee in August 2007 was noted. No assistive devices for walking were noted and the Veteran had an antalgic gait and no evidence of abnormal weight bearing. An x-ray of the left knee revealed minimal calcification in the menisci and the possibility of some degree of chondritis might be considered, although the left knee appeared to otherwise be normal. An x-ray of the right knee revealed findings indicating there may be very early osteoarthritic change suggested in the decrease in joint space and slight eburnation and changes suggesting chondritis, especially in the medial compartment. The Veteran was diagnosed with early arthritis of the bilateral knees (on x-ray) and status post right and left partial meniscus surgery (2006 and 2007). Following an examination of the Veteran's feet and back, the examiner furnished a medical opinion, finding that it was less likely than not that the Veteran's bilateral knee disability was secondary to limping caused by the service-connected left foot fibroma. He explained that there was documented evidence that the Veteran had a left foot fibroma excised in service and three other foot surgeries out fo service due to recurrent fibroma in 1997 and that the recurrent nature of fibromas was not related to military service, it was related to the nature of fibroma appearance. The examiner noted there was documented evidence that the Veteran's last foot surgery was in May 1997, more than 10 years earlier and the Veteran had not required any additional foot surgery. He noted there was documented evidence that the Veteran had a partial tear of the left Achilles tendon, noted in April 2007, which was casted and had a complete resolution of pain in that area per June 2006 private podiatry notes, which did not mention the appearance of another fibroma. The examiner also found that there was documented evidence that the Veteran was disabled due to his work related back injury and had three surgeries, there was documented evidence that the Veteran had early arthritis in both knees on x-rays, there was documented evidence that the Veteran had a bilateral partial meniscectomy in 2006 and 2007, there were subjective statements from the Veteran that he was in constant bilateral knee pain and there was documented evidence that prior orthopedic evaluation could not correlate limping as the cause of the bilateral knee condition. In addition, he noted that the left foot examination at that time revealed a tender spot, midway along the scar line with a small tissue accumulation that was soft by palpation and it was not possible to describe this tissue accumulation as a fibroma or residual scar tissue. In a November 2007 before a decision review officer (DRO) at the RO, the Veteran testified that he began to limp in 2004 and that the limp was due to a growth on the bottom of his foot, at which time his knees did not hurt. He then reported that all of a sudden his knees began to bother him and his regular doctor had taken x-rays which showed nothing. The Veteran testified that he then went to VA and they reported there was nothing wrong with his knees. He reported that his private physician Dr. B. decided he had arthritis in the right knee and a later physician, Dr. M., discovered meniscal tears and operated on his knees. The Veteran testified that he never had a problem before he started limping and believed his knee problems were due to his gait. The Veteran reported that he believed his physician, Dr. H., had said that his gait was causing his knee condition and then stated that all of his private physicians, verbally or in writing, supported that his left foot condition caused his knee problems and the only physician who had a different opinion was a VA physician who performed a VA examination. He testified that his gait was severely affected because of his foot condition and he did not have a problem with his knees prior to that time. A July 2008 VA outpatient treatment report reflects that the Veteran ambulated without assistance. March 2009 VA examinations of the foot and spine revealed no evidence of abnormal weight bearing and a normal gait. The examiner found that the Veteran's left foot condition was not causing any significant disability that was attributable to his physical or sedentary activities. He also found that the Veteran's lumbar spine condition, including demineralization of the L5 vertebral body and inferior aspect of the L4 with moderate degenerative change at L3-4 status post fusion and fixation device, was causing significant disability that was attributable to his physical and sedentary activities, specified as significant chronic abdominal discomfort (gastroparesis). A February 2009 VA outpatient treatment report reflects that the Veteran ambulated without assistance. In a May 2009 Travel Board hearing, the Veteran testified that his knee problems began back in 2002, when he began to limp due to his foot, that his limping became worse and the pain went into both legs. He stated his back got worse because of the limping and his foot growth had returned and gotten worse. The Veteran testified that his knees had collapsed on him in the last six months and he had fallen a couple of times. He reported seeing a private orthopedic specialist for both knees who removed the meniscus in both knees and he submitted those records to VA already. The Veteran stated that his private physician could not say for sure whether his knees were related to his service-connected back or foot and stated that nobody had said for sure what it was. The Veteran stated around 2006 or 2007 he was initially diagnosed with problems with the knees, before which, no one could see anything on x-rays. He reported that he never wore a brace although his knee had given out in the last six months. The Veteran testified that his knee problems included pain and prevention of walking and exercise. He then reported that no physician had ever related his knees to his left foot or his back and physicians had stated that there was no way they could prove it. The Veteran also reported that the March 2009 VA examiner would not listen to him and stated there was nothing wrong with his knees. The Veteran also reported that a VA physician had thought his knee disabilities were related to his back or foot. In a July 2009 statement, the Veteran's representative informed VA that the Veteran stated he received a medical opinion from a podiatrist at the VA medical center (VAMC) in Fort Myers, Florida, regarding his bilateral knee condition in June 2009. The Veteran believed this latest opinion fully supported his current claim for his bilateral knee condition. A review of all available VA medical records from June 2009 does not reflect any opinion regarding the knees was furnished. VA outpatient treatment reports from June 2009 and August 2009 reflect findings of no abnormal gait, atrophy, asymmetry or weakness upon musculoskeletal physical examination. Both reports were made by a VA podiatrist. In an April 2010 VA examination, the Veteran reported that he started limping in 2003, which was attributed to a recurrence of fibromata in the left foot and he then developed right knee pain with swelling and then developed similar symptoms in the left knee. Now he complained of pain in both knees, right greater than left, with shooting pain over the medical aspects and infrapatellar bilateral with weight bearing and being asymptomatic when at rest. Pain came and went and was localized with no radiation, was aggravated by walking, bending, the use of stairs and uneven surfaces or driving. Pain was relieved with rest, elevation and Aleve. The Veteran had not tried a brace or wrap. There was no reported improvement following surgical bilateral partial meniscectomies. The Veteran was noted to have an antalgic gait and was diagnosed with bilateral early osteoarthritis of the knees with calcification in the menisci, suggestive of pseudogout. The examiner opined that the Veteran's bilateral early osteoarthritis of the knees was less likely than not caused by or a result of service-connected lumbar post laminectomy syndrome with lumbar degenerative disease and/or recurring fibroma of the left foot. The examiner explained that the diagnosis of early osteoarthritis with decreased joint space and some calcification of the menisci was suggestive of pseudogout or chondrocalcinosis, etiologically on a degenerative arthritis basis, and therefore the presented knee condition was less likely causally related to the left foot or lumbar spine condition. The examiner also found that bilateral early osteoarthritis was less likely than not permanently aggravated by the service-connected lumbar post laminectomy syndrome with lumbar degenerative disease and/or recurring fibroma of the left foot. In September 2011, a VA examiner was asked to furnish an addendum opinion to the one provided in the April 2010 VA examination. The September 2011 VA examination report reflects that an additional examination was also conducted. At that time the Veteran reported he began having problems with his knees in 2003 with no history of injury. He reported a history of partial meniscectomies in 2006 and 2007. He related his right and left knee conditions to his limping caused by the recurrent fibroma of the left foot. An antalgic gait was noted upon physical examination. The Veteran was diagnosed with bilateral early osteoarthritis of the knees with calcification in the menisci, suggestive of pseudogout. The examiner opined that the bilateral early osteoarthritis of the knees was less likely than not caused by or permanently aggravated by the service-connected lumbar post laminectomy with lumbar degenerative disease and/or recurring fibroma of the left foot. He also found that the Veteran's altered gait (antalgic) less likely than not caused or aggravated his osteoarthritis of the knees. With regard to the Veteran's altered gait and whether it was due to his low back or left foot fibroma, he could not resolve that issue without resorting to speculation. The examiner explained that the previous orthopedic examination and opinion noted that the claimed limping was not caused by the fibroma of the left foot. He also noted that the current clinical findings could not support a causality of the claimed bilateral knee osteoarthritis and disability to his fibroma of the left foot and low back condition. The examiner found that there was no knowledge in medical literature that would support this causality. He also noted the physical examination showed stable cruciates and collaterals with no swelling, induration, ecchymosis or effusion and there was no atrophy of the quadriceps, hamstrings, gastrocnemius solus or peroneal muscle. He noted there was no leg length discrepancy. The examiner found that it was impossible ot determine in the altered gait was due to his left foot or low back disability. He noted that the Veteran claimed his altered gait was due to his left foot fibroma. The examiner also noted that a review of the claims file showed the Veteran injured his left foot in 1963 and injured his low back in 1967 and he underwent surgeries to the left foot and low back. He noted that nursing intake and primary care physician notes in the VA progress notes did not mention an antalgic gait but rather noted the Veteran was ambulatory without assistance. The examiner noted the antalgic gait was mentioned primarily in the VA examination. He also noted that a podiatrist consultation in June 2009 specifically noted "no abnormal gait" under the musculoskeletal examination. Finally, he found that, in the current physical examination, the Veteran was ambulatory with no assistive device, he appeared to be slightly limping but had full weight bearing on both feet and the wear and tear of both shoes was the same. Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). In considering both the April 2004 private physician's and June 2007 private podiatrist's conclusions and the April 2010 and September 2011 VA examiners' opinions, the Board notes that the VA examiners' opinions were both predicated upon the Veteran's reported history, a physical evaluation, and a review of the claims file including, the private medical opinions by the April 2004 private physician and June 2007 private podiatrist. The VA examiners also provided an extensive rationale to support their findings, including citing relevant findings from the Veteran's medical records and his reported history. While the April 2010 VA examination opinion was inadequate regarding the issue of aggravation, the September 2011 VA examiner provided and adequate explanation regarding aggravation of the bilateral knee disability. The Board notes that these opinions, have been found to be adequate except the April 2010 VA examination opinion regarding aggravation which is not relied up on by the Board in this decision. The Board finds these conclusions are consistent with the evidence of record and affords the April 2010 and September 2011 VA examiners' opinions greater weight than the opinions provided by the April 2004 private physician and June 2007 private podiatrist which merely provided conclusions that it was likely the Veteran's ongoing foot problems were contributing to his knee strain and the Veteran continued to have long term pain secondary to scar formation on the bottom of the left foot which may be contributing to an impaired gait, without providing any rationale for their conclusions. Therefore, the Board affords no probative weight to the April 2004 private physician's and June 2007 private podiatrist's conclusions and affords greater probative weight to the April 2010 and September 2011 VA examiners' opinions. After a review of the record, the Board concludes that entitlement to service connection for service connection for a right knee disability and a left knee disability, as secondary to service-connected lumbar post laminectomy syndrome with lumbar degenerative disease as well as recurring fibroma of the left foot, is not warranted. While the Veteran has a current diagnosis of bilateral knee osteoarthritis, there is no competent and credible evidence of any knee complaints, injury or treatment in service and the probative evidence of record does not demonstrate a nexus between the bilateral knees and either his active service or his service-connected left foot or lumbar disabilities. While not dispositive of the issue of whether service connection may be granted, the service treatment reports are absent of any treatment, findings or complaints related to the bilateral knees during the Veteran's active service. The Veteran does not contend that his knees disorders are related to his active service. The Board acknowledges that the Veteran has reported and testified that his private physicians and a VA podiatrist in June 2009 have related his bilateral knee disabilities to his service-connected left foot disability which he is competent to report. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, he is not competent to medically attribute any currently diagnosed bilateral knee disability to any other service-connected disability. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009). The evidence does not demonstrate that the Veteran has the requisite medical competence to diagnose or identify a bilateral knee disability or identify any etiology. As in Jandreau, the Veteran's assertions of causality have been investigated by competent medical professionals and found without merit. Moreover, while competent, the statements that the June 2009 VA podiatrist related the Veteran's bilateral knee disabiities to his service-connected left foot disability are not credible evidence as they are inconsistent with the contemporaneous medical evidence of record. The Board has an obligation to evaluate the credibility of evidence and to assign probative weight to competent evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (recognizing the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence"). As to some of the factors that go into making these determinations both the Court and the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) have provided guidance. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (stating that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc."); see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (stating that "[t]he credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character."). In this case, the evidence demonstrates that the Veteran was evaluated by a VA podiatrist in June 2009, was found to have no abnormal gait and the podiatrist did not comment on the Veteran's knee disabilities at all. Therefore, the statements noting that a VA podiatrist related the Veteran's bilateral knee disabilities to his service-connected foot, are inconsistent with the contemporaneous medical evidence of record. Jandreau, supra. The Board observes that the Veteran is competent to report that his private physicians have related his bilateral knee disabilities to his service-connected left foot disability and these reports are credible as they are supported by the April 2004 private physician's and June 2007 private podiatrist's opinions. See Baldwin v. West, 13 Vet. App. 1 (1999) (indicating the Board must additionally analyze the credibility of the evidence, so including the lay evidence, to in turn determine its ultimate probative value). The Board finds, however, that the private opinions provided by the April 2004 private physician and June 2007 private podiatrist were afforded no probative value as the Board afforded greater probative weight to the April 2010 and September 2011 VA examiners' opinions, which concluded that the bilateral early osteoarthritis of the knees was less likely than not caused by, a result of, or permanently aggravated by the service-connected lumbar post laminectomy with lumbar degenerative disease and/or recurring fibroma of the left foot. As noted earlier, these opinions have been found to be adequate. The Board also notes that in November 2003 Dr. J.S. stated that the Veteran had an ongoing chronic left foot problem and continued to have a limp which was causing discomfort in his lower back area. In addition, in November 2003 A.S., M.D. stated that the Veteran had chronic foot pain and was limping as a result which was markedly increasing his back pain. While these two examiners indicated that the Veteran had a limp due to his left foot disorder that was causing or increasing his back pain, neither indicated that it caused or aggravated his underlying low back disorder. This is an important distinction, i.e., that the limp was causing a symptom versus causing or aggravating an underlying disability. Thus, these examiners' statements are not found to be probative. In addition, the Veteran's representative referenced internet treatise articles for support of the premise that the Veteran's altered gait resulted in aggravation. However, these articles are not relevant to the facts of this specific Veteran's case and are not found to be probative. As noted above, in a reasoned opinion based upon the facts of this case, the April 2011 VA examiner concluded that, with regard to the Veteran's altered gait and whether it was due to his low back or left foot fibroma, he could not resolve that issue without resorting to speculation. Therefore, as there is no credible and probative evidence of a nexus between either the Veteran's active service and his currently diagnosed bilateral knee disabilities or between his bilateral knee disabilities and his service-connected left foot or lumbar spine disabilities, the preponderance of the evidence is against the Veteran's claims. As such, the claims for service connection for a right knee disability and a left knee disability, as secondary to service-connected lumbar post laminectomy syndrome with lumbar degenerative disease as well as recurring fibroma of the left foot, are denied. In reaching the conclusion above the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims for service connection for a right knee disability and a left knee disability, as secondary to service-connected lumbar post laminectomy syndrome with lumbar degenerative disease as well as recurring fibroma of the left foot, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Service connection for a right knee disability, as secondary to service-connected lumbar post laminectomy syndrome with lumbar degenerative disease as well as recurring fibroma of the left foot, is denied. Service connection for a left knee disability, as secondary to service-connected lumbar post laminectomy syndrome with lumbar degenerative disease as well as recurring fibroma of the left foot, is denied. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs