Citation Nr: 1322672 Decision Date: 07/16/13 Archive Date: 07/24/13 DOCKET NO. 09-31 735 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected disability. 2. Entitlement to service connection for a left foot/ankle disorder, to include as secondary to service-connected disability. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected disability. REPRESENTATION Appellant represented by: National Association for Black Veterans, Inc. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD David S. Nelson, Counsel INTRODUCTION The Veteran had active service from April 1982 to June 1983. These matters come before the Board of Veterans' Appeals (BVA or Board) from an April 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, on behalf of the RO in Portland, Oregon. This case was previously before the Board in November 2012 and was remanded for further development. In September 2012 the Veteran testified during a Board hearing before the undersigned at the RO. A transcript of that hearing is of record. FINDINGS OF FACT 1. A disease or injury of the Veteran's left knee did not have onset during his active service or within one year thereafter, was not caused by his active service, and was not caused or aggravated by a service-connected disability. 2. A disease or injury of the Veteran's left foot or left ankle did not have onset during his active service or within one year thereafter, was not caused by his active service, and was not caused or aggravated by a service-connected disability. 3. The Veteran's hypertension did not have its onset during his active service or within one year thereafter, was not caused by his active service, and was not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for disability of the left knee have not been met. 38 U.S.C.A. §§ 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2012). 2. The criteria for service connection for disability of the left foot and left ankle have not been met. 38 U.S.C.A. §§ 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2012). 3. The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in October 2007 of the criteria for establishing direct and secondary service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates if service connection is awarded. This letter accordingly addressed all notice elements and predated the initial adjudication by the AOJ/RO in April 2008. Reference is made to an April 2013 Report of Contact wherein it was noted that the Veteran stated that he had not received a March 2013 supplemental statement of the case (SSOC). The SSOC was subsequently received by the RO as returned/undeliverable mail. The SSOC was re-mailed to the Veteran in April 2013. There is no indication that the mailing of April 2013 was returned or otherwise not delivered to the Veteran. Indeed, it appears that the Veteran has continued to receive VA correspondence subsequent to March 2013 (for example, an April 2013 informational letter from the Board) at the address in question. As for VA's duty to assist, service treatment records are associated with the claims file, as are VA medical records, private medical records, and the Veteran's Social Security Administration (SSA) records. The Veteran has not referenced any other pertinent, obtainable evidence that remains outstanding. Notably, a January 2013 letter from the AOJ to the Veteran notified him that he must return the supplied VA Form 21-4142, Authorization and Consent to Release Information (VA Form 21-4142), for any additional treatment records he wished to have VA obtain for him. No VA Form 21-4142 authorizing VA to obtain records was submitted. In February 2013 the Veteran underwent a VA examination that addresses the medical matters presented by this appeal. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 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 Board finds that the VA opinion obtained in this case is more than adequate. The February 2013 VA examiner elicited information concerning the Veteran's military service and performed a contemporaneous physical examination. The opinion considered the pertinent evidence of record and provided a rationale for its conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). During the September 2012 Board hearing, to assist the Veteran, the undersigned asked questions to determine if there was any evidence outstanding pertinent to his claims. The undersigned also asked questions to help direct the Veteran's testimony concerning the onset of his claimed disabilities and also asked whether any medical professional had given any opinions relating the disabilities on appeal to any of his service-connected disability. The undersigned attempted to direct the Veteran away from repeatedly discussing current symptoms to that of assisting the Veteran in understanding the necessity of providing medical nexus evidence useful to his claims. These actions fulfilled the duties in Bryant v. Shinseki, 23 Vet. App. 488 (2010), and the Veteran has not asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) or identified any prejudice in the conduct of the hearing. As such, the Board finds that, consistent with Bryant, the Board complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claims based on the current record. The Board finds that there has been substantial compliance with its November 2012 remand instructions. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Significantly, as noted, in February 2013 the Veteran underwent a VA examination that addressed the medical matters presented by this appeal and contained answers to specific questions enumerated in the November 2102 remand. In January 2013 VA was informed that there were no records pertaining to the Veteran's treatment for hypertension at the Presidio Army medical center. In view of the negative response, in March 2013 the RO contacted the Veteran and asked if he had any records in his possession. He indicated that he had none. VA's duties to notify and assist are met. The Board will thereby address the merits of the claims. Applicable Laws-Service connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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). To establish a right to compensation for a present disability, a Veteran must show: (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. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection for certain specified chronic diseases, such as arthritis and hypertension may be established on a presumptive basis by showing that such disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted, on a secondary basis, for a disability, which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310 (2012). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). VA is required to evaluate the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the veteran served, the veteran's military records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). The Board notes that although all the evidence has been reviewed, only the most salient and relevant evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). At the September 2012 Board hearing the Veteran's representative stated that no medical professional had given an opinion stating that the Veteran's left knee disability was caused or made worse by the symptoms related to his back disability. The Veteran stated that he was punished during service by being forced to be on his knees with a log on his neck for 30-40 minutes at a time. The Veteran stated that his hypertension resulted from the stress he had during service, but he indicated that he had no treatment or concern for hypertension during his active service. The Veteran recalled that he had first been diagnosed with hypertension in 1987 at Presidio. The Veteran's representative reiterated the Veteran's contentions that his knee and feet disabilities were related to the service-connected low back condition, "which extends from the left iliac area where the hematoma was." I. Service connection for a left knee disorder and left foot/ankle disorder The Veteran's service treatment records do not reflect any complaints or diagnoses of left knee, left foot, or left ankle disability. The Veteran's May 1983 service separation examination reveals that his lower extremities and musculoskeletal system were clinically evaluated as normal, and the Veteran specifically denied that he had any foot trouble or locked knee on the corresponding report of medical history. Post service private medical records and records received from the SSA show that the Veteran has been followed primarily for complaints of low back and left hip pain. There are references to him having complaints of left knee and left foot pain. A September 2008 MRI of the left knee indicated that the Veteran had injured his knees 15 years earlier (1993) and stated that he had to have fluid removed from his knees over the years. The MRI revealed mild degenerative osteoarthritic changes. None of those records associate any disorder of the left knee or foot to the Veteran's active service or service connected low back or left hip disorder. As for VA records, a July 2000 VA record noted that the Veteran complained of severe bilateral foot pain. He was seen in November 2000 for complaints of generalized join pain. There was slight knee effusion. Questions regarding Reiters syndrome and rheumatoid arthritis were raised. At a May 2012 VA examination the Veteran asserted that he had left knee disability related to his service-connected disabilities. However, as a knee disorder was not diagnosed at that time or found in the service treatment records, an etiology opinion was not rendered. At the February 2013 VA examination the Veteran indicated that he had experienced bilateral knee pain for as long as he could remember. He denied any history of injury. The diagnosis was left knee arthritis and left knee patellofemoral syndrome. The examiner noted that the Veteran had left foot hallux valgus and 1st metatarsophalangeal (MP) joint degenerative arthritis. It was noted that the Veteran had pain in his left foot of long duration with no history of injury. The diagnosis was left foot arthritis. However, based on examination and X-rays, the Veteran had no left ankle condition. The examiner went on to state that the Veteran's left knee and left foot disorders were not incurred or otherwise related to his active service, including the rigors and punishment during boot camp. Reference was made to absence of any documented treatment for knee and foot problems as well as the negative discharge examination. He added that there was also no evidence of any disorder of the knee until many years post-service. He believed that any mild degenerative joint disease of the knee would be the result of aging. The patellofemoral syndrome was nothing more than a condition that was secondary to the knee itself. As for the Veteran's left foot, the examiner explained that the arthritis was the result of his hallux valgus (which was an acquired condition) and aging. He also indicated that any neurological complaints in the left foot would be due to the Veteran's non-service connected diabetes mellitus. The examiner added that it was less likely than not that the Veteran's left knee and foot disabilities were caused or aggravated by his service connected low back and left hip disabilities. He indicated that there had been no progression of the arthritis when comparing X-rays from 2008 to those from 2012. He also indicated that the Veteran's gait had not been impaired by his back and hip disabilities. The Board finds that the preponderance of the competent and credible evidence does not show that the Veteran's left knee disability and disability of the left foot are related to his service-connected disabilities. The February 2013 VA examiner, after reviewing the Veteran's claims file and performing a contemporaneous examination, clearly stated that the Veteran's current left knee and left foot arthritis and hallux valgus disorders were not caused or aggravated by any of the Veteran's service-connected disabilities. The February 2013 VA examiner provided a sound rationale for the opinion expressed and even provided an opinion of etiology concerning the left knee and left foot disorders. In this regard, the Board notes that the February 2013 VA examiner indicated that the Veteran's left knee arthritis was secondary to the aging process and that his left knee patellofemoral syndrome was related to the anatomy of the Veteran's knee. The examiner also stated that there had been no progression of the Veteran's mild left knee arthritis since September 2008, as reflected in diagnostic studies. Further, the examiner stated that the Veteran's left foot condition, mild hallux valgus, was an acquired condition, and he further stated that the Veteran's left foot mild degenerative arthritis was secondary to the mild hallux valgus and the natural aging process. The examiner also observed that Veteran's mild gait abnormality did not appear to be altered or impaired to cause any significant aggravation of the Veteran's left foot conditions. The foregoing review of the February 2013 VA examination reveals that the examiner has identified a specific etiology to every diagnosed left knee or left foot condition, and those etiologies reveal that the left knee and left foot disorders identified were not caused or aggravated by service-connected disability or otherwise related to service. The February 2013 VA examiner's opinion is essentially uncontradicted. The Veteran's assertion that his left knee and left foot disabilities are secondary to his service-connected disabilities has been considered. To the extent that this is an opinion of a nexus between these conditions, the Board finds that his statement is not competent evidence. Whether a layperson opinion as to a nexus or a diagnosis is competent evidence depends on the facts of the particular case. See Davidson v. Nicholson, 581 F.3d 1313 (Fed. Cir. 2009). One factor for consideration is the complexity of the question to be determined. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (providing an example in footnote 4 that a layperson would be competent to diagnose a simple condition such as a broken leg but not competent to diagnose a form of cancer). Another factor is whether the question can be answered by personal observation alone. See Layno v. Brown, 6 Vet. App. 465, 496 (1994) (explaining that a layperson is competent to report only that which he or she observed). Whether one or more disabilities (such as the Veteran's back, left hip, etc.) can cause or aggravate pathology in another joint (in this case, the left knee or left foot) is not a question that can be determined by mere observation. Given that there is no logical or obvious relationship, it is not a simple question. For these reasons, the Board finds that his opinion in this regard is not competent evidence and therefore not probative of any fact in this case. Based on the foregoing, the Board concludes that the preponderance of the competent and credible evidence shows that the Veteran's left knee or left foot disability is not caused or aggravated by any of the Veteran's service-connected disabilities. As for direct service connection, the Veteran's service treatment records reveal that a left knee, left foot, or left ankle disability was not noted in service. This is evidence that he had no injury or disease of his left knee or left foot during service or any symptoms of such and is therefore evidence unfavorable to his claim. While the claims file contains numerous orthopedic evaluations undertaken in connection with his SSA claim, these records do not show or contain any evidence suggesting a relationship between left knee or left foot disability and the Veteran's service. In the same manner, the VA records, including those from rheumatology dated in the 1990s, also do not link any such disability to the Veteran's active service. The February 2013 VA examiner specifically stated that the Veteran's left knee and left foot disabilities were not related to the Veteran's active service. This report is evidence against the Veteran's claim. To the extent that the Veteran now argues that his current left knee and left foot disabilities had their onset in service or are otherwise etiologically related thereto, such statements to lack credibility. Considerable emphasis is placed on the fact that the Veteran made no reference to chronic knee or foot problems when he filed claims for benefits in 1990 and 1998. He also specifically denied that he had any foot trouble or locked knee problems at the time of his separation from service. Further, no such complaints were made at the November 1994 orthopedic evaluation undertaken in connection with his SSA claim. Had the Veteran been experiencing left knee or left foot troubles at the time he was filing for SSA benefits the Board believes that he would have mentioned such to the examiner. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (where there is a lack of notation of medical condition or symptoms where such notation would normally be expected, the Board may consider this as evidence that the condition or symptoms did not exist). The Board also notes that the private September 2008 left knee MRI record indicates that the Veteran's knee pain had started 15 years prior, a time that would be roughly 10 years subsequent to his active service. Finally, the Veteran initially stated in his August 2007 claim that both conditions had their onset on or around 2002, and that they were secondary to his back disorder. All of the above severely undermines any current argument that his knee and foot problems had their onset service. It also negates any argument of continuity of symptomatology. Consideration is also given to the argument that the Veteran's knee and foot disorders are related to the stresses and strains of his active service. However, aside from the lack of credibility of that assertion, which is discussed above, the Board finds that the Veteran's lacks the competency to make such a contention. 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 issues here, orthopedic disorders, including arthritis, 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). Arthritis, patellofemoral syndrome, and hallux valgus are not the type of conditions that are readily amenable to mere lay diagnosis or probative comment regarding their etiology, as the evidence shows X-ray studies and other specific findings are needed to properly assess and diagnose the disorders. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that Veteran is competent to report knee and foot pain, there is no indication that the Veteran is competent to etiologically link these reported in-service symptoms to his arthritis, patellofemoral syndrome, and hallux valgus sleep apnea, which were all diagnosed several years after his discharge. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating orthopedic disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. Finally, there is no objective evidence, or even an assertion by the Veteran, that he was diagnosed as having left knee arthritis or left foot arthritis within one year of his service discharge. Left knee arthritis was not shown until September 2008, and left foot arthritis was not shown until May 2012. A review of the evidence has revealed that a disease or injury of the Veteran's left knee, left foot, or left ankle did not have onset during his active service, was not caused by his active service, and was not caused or aggravated by a service-connected condition. As the preponderance of evidence is unfavorable to his claim, the Board must deny her appeal as to entitlement to service connection for left knee, left foot, and left ankle disorders. There is no reasonable doubt to be resolved as to these issues. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. II. Hypertension The Veteran's service treatment records do not reflect any complaints or diagnoses of hypertension or heart disability. The Veteran's May 1983 service separation examination reveals that his heart was clinically evaluated as normal; blood pressure was recorded as 104/68. The Veteran specifically denied that he had any high blood pressure on the corresponding report of medical history. A May 1997 VA record noted that the Veteran had a family history of hypertension. A July 1998 VA record noted that the Veteran was to be followed for hypertension and that no medications were needed. An August 2007 VA clerical note indicated that the Veteran was advised to have his representative request an evaluation for his hypertension as "possibly an adjunct condition" to his back pain. An August 2007 VA physical examination indicated a diagnosis of hypertension, untreated. At a February 2013 VA examination the Veteran stated that he was first diagnosed with hypertension in the late 1990s and that he had taken medication on and off since that time. The Veteran stated that the stress of life had caused his condition. The examiner stated that the Veteran had hypertension but that it was not incurred in during or otherwise related to the Veteran's active service. The examiner noted that the Veteran had no elevated blood pressure during service or until 2006. The examiner also stated that the Veteran's hypertension was not caused or aggravated by service-connected low back, left hip, or left iliac scar disability. The examiner indicated that the Veteran's hypertension was likely genetic. The examiner further noted that the onset of the Veteran's high blood pressure was in keeping with the natural progression of his condition. The Board finds that the preponderance of the competent and credible evidence does not show that the Veteran's hypertension is causally related to his service-connected disability. The February 2013 VA examiner, after reviewing the Veteran's claims file and performing a contemporaneous examination, provided a rationale for the opinion expressed. The February 2013 VA examiner referenced multiple clinical records of the Veteran, including numerous blood pressure readings from the time of the Veteran's active service until the time of the February 2013 VA examination. The examiner did more than just state that the Veteran's hypertension was not related to service or service-connected disability; the examiner rendered an etiology of the Veteran's hypertension, stating that it was genetic. The examiner's opinion is essentially uncontradicted. Consideration has clearly been given to the August 2007 VA clerical note, which suggested that there could be a relationship between the Veteran's hypertension and his back pain. However, there was no rationale provided with the opinion. Further, while not necessarily outcome determinative, there is no indication that the care provider had the benefit of reviewing the complete claims file or considered the Veteran's familial history. It is for these reasons that the 2007 note carries less probative value than the VA examiner's 2013 opinion. The Veteran's assertions that his hypertension is secondary to his service-connected disabilities has been considered. To the extent that this is an opinion of a nexus between these conditions, the Board finds that his statement is not competent evidence. Whether one or more disabilities (such as the Veteran's back, left hip, etc.) can cause or aggravate hypertension is not a question that can be determined by mere observation and is not a simple question. For these reasons, the Board finds that his opinion in this regard is not competent evidence and therefore not probative of any fact in this case. Based on the foregoing, the Board concludes that the preponderance of the competent and credible evidence shows that the Veteran's hypertension is not caused or aggravated by any of the Veteran's service-connected disabilities. As for direct service connection, the Veteran's service treatment records reveal that hypertension was not noted in service, including on the Veteran's May 1983 service separation examination. The report of medical history at separation shows that the Veteran denied a history of high blood pressure and the separation examination shows that blood pressure was 104/68. No heart defects or diagnoses were noted on the separation examination report, and there is no medical opinion relating such disability to the Veteran's military service. Significantly, the February 2013 VA examiner specifically noted that the Veteran's hypertension was not related to his military service. There is also no objective evidence that the Veteran was diagnosed as having hypertension within one year of his service discharge. In fact, at his September 2012 Board hearing the Veteran specifically stated that he had not been diagnosed with hypertension until 1987, approximately 3-4 years following service. Further, when he was evaluated by VA in November 1990 (the earliest VA treatment record associated with the claims file), which included a blood pressure reading of 110/84, a diagnosis of hypertension was not made. Under certain circumstances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, the Veteran is not competent to establish a matter that requires medical knowledge, such as providing the etiology of his hypertension. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Any assertion of continuity of symptomatology of hypertension is not supported by the record. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by the veteran). The Board again notes that the Veteran denied a history of high blood pressure at the time of his service separation examination. Further, and as previously discussed, the Veteran has testified that the earliest he sought treatment for hypertension was 3-4 years following service. The Board can find no findings of high blood pressure or hypertension until the 1990s. As such, the preponderance of the evidence is against service connection for hypertension, on a direct or secondary basis. In sum, the criteria for service connection for hypertension are not met. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence weighs against the claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for left knee disorder, to include as secondary to service-connected disability, is denied. Service connection for a left foot or left ankle disorder, to include as secondary to service-connected disability, is denied. Service connection for hypertension, to include as secondary to service-connected disability, is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs