Citation Nr: 1324735 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 04-19 008 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to service connection for residuals of a left knee injury with healed lacerations. REPRESENTATION Veteran represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD Sara Schinnerer, Counsel INTRODUCTION The Veteran served on active duty from June 1968 to August 1968. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from March and June 2003 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In September 2005, the Board reopened the claim on appeal and remanded the case for further development. In April 2006, the Board again remanded the claim so that additional development of the evidence could be undertaken. In October 2006, the Board denied the claim for service connection for residuals of a left knee injury with healed lacerations. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court), and, in a December 2008 memorandum decision, the Court vacated the Board's decision and remanded the matter to the Board. In August 2010, the Board again denied the claim, and the Veteran appealed the decision to the Court. In a May 2011 Order, the Court vacated the August 2010 Board decision and remanded the matter to the Board for development consistent with the parties' April 2011 Joint Motion for Remand (Joint Motion). In October 2011, the Board remanded the Veteran's claim for additional development. In March 2012, the Board again remanded the Veteran's claim for additional development. In March 2013, the Board again denied the Veteran's claim for service connection for residuals of a left knee injury with healed lacerations. In May 2005, the Board vacated its March 2013 decision. FINDINGS OF FACT 1. A pre-existing knee disorder was noted on a May 1968 enlistment examination report. 2. A pre-existing left knee disorder underwent a temporary flare-up of symptoms during active duty without a permanent worsening of the underlying left knee condition. 3. A current left knee disability is not the result of a temporary flare-up of symptoms during active duty of a pre-existing left knee condition. CONCLUSION OF LAW The requirements for service connection for a current left knee disability based on aggravation of a pre-existing left knee condition have not been met. 38 U.S.C.A. § 1153 (West 2002 & Supp. 2012); 38 C.F.R. § 3.306 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it 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 the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, the Board acknowledges that the RO did not provide the Veteran with adequate notice prior to the initial decisions in March 2003 and June 2003. Nevertheless, the RO sent the Veteran letters in November 2001, July 2003, May 2005, and September 2005 that informed him about the evidence necessary to substantiate his claim and the division of responsibilities in obtaining the evidence. Because the claim was subsequently readjudicated, the Board finds that any defect with respect to the timing of the notice requirement was harmless error. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). For these reasons, the Board finds that the content requirements of the notice VA is to provide have been met, and no further development is required regarding the duty to notify. Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004). Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim. The Board also concludes that VA's duty to assist has been satisfied. 38 U.S.C.A. § 5103A. Service treatment records, private treatment records, and records from the Social Security Administration (SSA) are on file. The Veteran has at no time referred to records that he wanted VA to obtain or that he felt were relevant to the claim that VA has not obtained on his behalf. Moreover, in addition to obtaining all relevant medical records, VA afforded the Veteran a VA examination in November 2011 in conjunction with his claim. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that "once the Secretary undertakes the effort to provide an examination when developing a service-connection claim, . . . he must provide an adequate one"). The Board remanded the Veteran's claim in March 2012 for clarification of the November 2011 medical opinion. Specifically, the VA examiner was asked to cite to the pertinent service treatment records used as a basis for the opinion, to include the May 1968 report of medical history and the July 1968 service treatment record, and discuss the Veteran's statements made during the VA examination as well as his lay statements throughout the pendency of the appeal indicating that his left knee disorder became worse during service. The VA examiner was also asked to comment on the medical opinions provided by the Veteran's private physician. Accordingly, in May 2012, the Veteran's claim was referred to the VA examiner who performed the November 2011 examination for an additional medical opinion. However, because the VA examiner's opinion failed to comply with the Board's specific remand instructions, the Veteran's claim was forwarded to another VA examiner, who provided a medical opinion dated in July 2012. The July 2012 VA examiner noted that he reviewed the entire claims file and cited to the Veteran's service treatment records. The VA examiner commented on the private physician's medical opinion and addressed the Veteran's lay statements on VA examination and throughout the appeal period. Therefore, the Board finds the RO complied with the March 2012 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). The Board acknowledges the assertions of the Veteran and his representative, namely, that the November 2011 VA examination, May 2012 VA addendum, and the July 2012 VA opinion were inadequate for adjudication purposes. In her April 2013 submission, the Veteran's representative asserted that such examination and subsequent opinions were inadequate because each examiner failed to provide an adequate rationale for their opinions. Specifically, the Veteran's representative argued that the Veteran's knee was normal upon entrance into service, and that the examiners did not consider all of the evidence of record, and appeared to rely on the Veteran's reported history of knee problems at enlistment, and ignored the other aspects of the Veteran's enlistment examination that found his knees to be stable at that time. In this regard, the Board finds that the examiners appropriately based their opinions upon the finding that the Veteran had a pre-existing left knee disorder, as per the aftermath of the Court's December 2008 Memorandum Decision, which will be discussed at length below. The Veteran's representative further argued that the aforementioned VA opinions were inadequate in light of Dr. T.S.'s opinions that link the Veteran's left knee disorder to his service. In this regard, the Board finds Dr. T.S.'s opinions to be speculative at best, as he failed to provide a rationale for his opinion, nor did he address the pertinent clinical evidence of record, to include the December 1968 VA examination findings. Moreover, Dr. T. S. does not appear to consider the issue of aggravation of an injury incurred prior to active duty, which has been established by the record and ordered by the Court. Next, the Veteran's representative argued that the examiners opinions were not sufficient to establish that the Veteran's left knee condition was not aggravated by service. Here, the Board finds that such opinions were sufficient to establish that the Veteran's left knee condition was not aggravated by service; specifically, the July 2012 examiner made such a determination based on the Veteran's x-ray findings, the medical resonance imaging (MRI) scan, and the clear documentation, to include the July 1968 service treatment record noting a history of intermittent locking and pain of the left knee at age 14. Finally, the Veteran's representative argued that the VA examination and opinions were not thorough, because the examiners failed to adequately consider the Veteran's lay statements and J.B.'s lay statement. In this regard, the July 2012 VA examiner specifically noted and addressed the Veteran's contentions, which will be discussed in depth below, and he considered all of the evidence of record. Accordingly, the Board finds that the November 2011 VA examination findings, in combination with the additional medical opinions provided in May 2012 and July 2012, is adequate. In particular, the July 2012 VA opinion was predicated on a review of the entire claims file and the examiner provided sound reasoning for the opinion, relying on and citing to the record reviewed. Neives-Rodriquez v. Peake, 22 Vet. App. 295 (2008). For these reasons, the Board finds that VA has fulfilled the duty to assist the Veteran in this case. LAW AND ANALYSIS Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110. Service connection may also 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). In order to establish direct service connection for a disability or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. This presumption of sound condition attaches only where there has been an induction examination in which a disease or injury was not noted but which manifested or was incurred in service. Gilbert v. Shinseki, 26 Vet. App. 48, No. 11-2355, 2012 WL 5233422 (Vet. App. Oct. 24, 2012) ("Once the presumption of soundness is applied, if the Secretary is unable to rebut the presumption, the disease or injury that manifested in service is deemed incurred in service, such that the second element of service connection is established."); see also Holton v. Shinseki, 557 F.3rd 1362, 1366 (Fed.Cir. 2009) (noting that 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). The term "noted" in section 1111 of the statute denotes only such conditions as are recorded in examination reports. History provided by the veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a pre-existing condition. 38 C.F.R. §§ 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). Where a pre-existing disease or injury is noted on the entrance examination, section 1153 provides that "[a] pre-existing injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease." 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable evidence is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service, and clear and unmistakable evidence includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups of symptoms of a pre-existing condition, alone, do not constitute sufficient evidence for a non-combat veteran to show increased disability for the purposes of determinations of service connection based on aggravation unless the underlying condition worsened. Davis v. Principi, 276 F.3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306(b). The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, will not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1). 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. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. A May 1968 enlistment examination report demonstrates the Veteran reported a medical history of a "trick" or locked knee. The Veteran also noted that prior to service he had 34 stitches in his left leg. However, the examiner noted "knee stable" on the enlistment examination report, and on a clinical evaluation, found the Veteran's lower extremities to be normal. Thus, the Veteran was found fit for active duty. Although history provided by the Veteran of a pre-existing condition which is recorded upon entry onto active duty does not, in itself, constitute a notation of a pre-existing condition for the purposes of applying the presumption of soundness, the Court, in a December 2008 Memorandum Decision, held that the Board's finding in its prior decision in this case that a left knee disorder was "not noted" upon entry was clearly erroneous. 38 C.F.R. § 3.304(b)(1); Paulson, 7 Vet. App. at 470; Crowe, 7 Vet. App. at 246. As a result, the Court vacated the Board's prior decision and reversed that finding and also reversed the Board's conclusion that the presumption of soundness at entry onto active duty applied in this case. Therefore, pursuant to the Court's determination, the Board now finds the presumption of soundness does not apply in this case with regard to the left knee. Therefore, the remaining questions are whether a pre-existing left knee disorder was aggravated during active duty in 1968, and if so, whether a current left knee disability is the result of that aggravation. 38 U.S.C.A. §§ 1110, 1153; 38 C.F.R. § 3.306. A July 1968 service treatment record indicates the Veteran sought treatment for his left knee. The Veteran complained that he was unable to keep up with his company. Because the Veteran was unable to walk, and effusion was present, the Veteran was referred for an orthopedic consultation. It was noted that a disease of the left knee existed prior to active duty and that the Veteran had a recurring knee problem. The Veteran was seen in an orthopedic clinic in July 1968 with complaints of pain and effusion in his left knee. He reported a three-year history of intermittent locking and pain in his left knee joint. The injury was attributed to football, and the Veteran indicated that he had been on crutches for most of the previous summer. It was noted that the Veteran's knees continued to be painful, and a physical examination revealed mild quadriceps atrophy, medial joint line tenderness, and a positive McMurray's test. However, the Veteran had full range of motion, and there was no effusion. The examiner diagnosed a torn left medial meniscus that pre-existed active duty, and separation from service was recommended. The Veteran was placed on profile for torn cartilage of the left knee pending his separation, and he was restricted from crawling, stopping, running, jumping, prolonged standing, and marching. Medical Board Proceedings dated in July 1968 document that the Veteran had a history of intermittent locking and pain in his left knee joint that began when he was 14 years old. The Members of the Board found that a left knee disorder existed prior to service was not aggravated by active duty. It was recommended that the Veteran be separated from service as a result of his pre-existing left knee disorder. On the Veteran's July 1968 report of medical history, he stated that his health was generally good "except for my knee which bothers me." He reported that he previously had 25 stitches in his leg which was "right under [his] wounded knee." His July 1968 separation examination demonstrates notations of "torn ligament left knee" and "tear, old medial meniscus . . . ." The Veteran submitted a claim for service connection in August 1968. He reported that he had torn ligaments and torn cartilage in his knee "which was done in the service during active duty." The Veteran underwent VA examination in December 1968, wherein he reported that his left knee gave him trouble and pain when he had the flu at the age of 15. Prior to that time, he had sustained a cut on the inner side of his left upper tibia which had left the residual scar. The Veteran did not describe an injury in service, nor did he relate an account of symptom development or the means by which his symptoms were produced or relieved. He stated that he had not sought medical advice or taken any pain medication since service; he did state, however, that his left knee pain had become unbearable. On physical examination, there were no signs of inflammation, instability, cartilage derangement or injury, popliteal bulge, or ligamentous laxity. There was no crepitus, excess fluid, or loose body. The tibial tubercles appeared normal and did not suggest any epiphysitis residuals. X-rays were normal, and comparative circumference measurements of the thighs suggested that serious disease of the left knee was absent. The remainder of the examination was normal, and reflexes were equal and active throughout. The VA examiner stated that the reported symptoms were bilateral, which suggested that the derangement, if present, was congenital or that the Veteran's complaints were on a hysterical basis. The VA examiner diagnosed a healed laceration of the left knee with a healed scar on the upper tibia, which pre-existed service. In a July 1995 written statement, the Veteran asserted that he injured his leg in basic training. On VA examination in April 1996, the Veteran reported a history of chronic left knee pain since 1968. He stated that he had injured his left knee during basic training, although he did not recall the details of the injury. He reported recurrent episodes of left knee pain, stiffness, swelling, clicking, occasional instability, and occasional locking. Physical examination revealed mild to moderate cyanotic ring around the knee cap but no fluid, erythema, or increased temperature. The Veteran had mild tenderness over the medial tibiofemoral joint line as well as patellar tendon tenderness. There was no swelling or erythema over the patellar tendon, flexion was mildly restricted, and extension was normal. The Veteran's knee was positive for McMurray's test, negative for varus and valgus stress, and negative for drawer. Coarse crepitation was present. The VA examiner diagnosed chronic bilateral knee arthralgia and patellar tendinitis. A May 1995 private treatment record documents the Veteran's report that he had injured his left knee in service. However, the Veteran could not remember the nature of the injury or the circumstances. He stated that he had not injured his knee since service and that his knee had never caused him any problems until he began to look for work. A November 2000 VA treatment record indicates the Veteran reported left knee pain; however, x-ray examination showed a normal left knee. A history of locking and instability was noted. The Veteran's range of motion seemed stiff. An April 2001 VA treatment record demonstrates the Veteran reported left knee pain and torn ligaments in the left knee. The Veteran had no obvious injury since 1968. An additional April 2001 VA treatment record indicates the Veteran had a normal x-ray. The Veteran reported that he injured his left knee during active duty in 1968 and was hospitalized at Madigan Hospital. The Veteran was unsure of the exact nature of his hospital course, but the VA physician opined that it seemed he had "some sort of ligamentous repair surgery." The VA physician determined that the Veteran had a medial surgical incision just distal to the joint line. The Veteran did not remember any other cause for the scar other than the original knee injury. The VA physician stated the Veteran had a complicated history as he had some chronic knee pain since 1968. On physical examination, the Veteran was unable to straighten his knee, and there was an approximately 20 degree flexion deformity. There was exquisite tenderness to the touch, fairly diffusely, but increased tenderness particularly at the medial joint line as well as the anserine bursa region. The VA physician diagnosed chronic left knee pain with chronic flexion deformity of at least 25 to 30 years in duration. The VA physician found the Veteran had developed a chronic pain syndrome involving his left knee. In an April 2001 written statement, the Veteran asserted that he had hurt his left knee during basic training at Fort Lewis, Washington, in 1968. He stated that he was treated at Madigan Hospital for a torn ligament and had continued to have problems since service. The Veteran also submitted a buddy statement in December 2001. The buddy stated that he had known the Veteran since 1951 and that prior to the Veteran's entry into service he had no problems with his knee. The Veteran's buddy stated that he visited the Veteran while he was stationed at Fort Lewis, Washington, where he observed that the Veteran had severe problems with his knee. A written statement also received in December 2001 shows the Veteran reported that his knee injury was sustained in active duty. A May 2001 VA treatment record noted the Veteran had left knee pain, locking, and instability. It was recorded that he was discharged from service for the same condition. In the Veteran's May 2003 Notice of Disagreement, he contended that he had no disabilities at the time of his entry into service. He asserted he was hospitalized in the base hospital at Fort Lewis for 21 days. A May 2003 VA treatment record demonstrates the Veteran reported increased difficulty walking due to left knee pain, and he was provided with a standard cane to assist with ambulation. May 2003 x-rays revealed no fractures, dislocations, or effusions. Mineralization and joint spaces were normal. The impression was normal knees. In support of his claim, the Veteran submitted a July 2003 private medical opinion from Dr. T. S. Dr. T. S. reported that the Veteran was injured during basic training in 1968. He found the Veteran had been bothered with the same problem since service and now used a cane. Dr. T. S. stated the Veteran had decreased mobility, stiffness, and rigidity of the left knee, which also resulted in low back pain and right knee pain. Dr. T. S. opined that the Veteran's current disability was "clearly related to his injury in the service" and that the Veteran's current problems were "directly related to his injury in basic training." The Veteran also provided a January 2004 private medical opinion from Dr. T. S. Dr. T. S. reported that the Veteran had a permanent flexion contracture of the left knee stemming from a service-connected injury in 1968. He stated the Veteran was not able to extend his knee beyond 150 degrees or flex his left knee beyond 100 degrees. The Veteran had warmth and swelling and needed a cane. Dr. T. S. stated that the Veteran had brought him a service disability claim showing that he had torn ligaments and cartilage in his left knee on July 24, 1968 in basic training at Fort Lewis, Washington. Dr. T. S. stated, "Certainly, it appears to be very straight forward that his current problems regarding his knee are related to a service-connected injury." Dr. T. S. also provided a medical opinion in February 2004, stating that it was "at least and likely as not" to have an injury as the result of his service-connected tear of the medial meniscus. He also determined that it was "at least as likely as not" that the Veteran's knee condition "may be the result of the aggravation of his meniscus tear during basic training." Dr. T. S. noted that the Veteran had documented torn ligaments and cartilage in his left knee stemming from a July 1968 injury incurred in basic training at Fort Lewis, Washington. In a November 2005 written statement, the Veteran asserted that his injuries and problems started in 1968 while on active duty. In a November 2007 brief to the Court, the Veteran's representative argued that a July 1968 service treatment record demonstrated a dramatic change in the condition of the Veteran's left knee during active duty. The representative asserted that the Veteran's knee was stable at the time of induction, yet was so badly injured only two months later that he had to be medically discharged. Therefore, according to the Veteran's representative, any pre-existing knee injury must have been aggravated by active duty. The Veteran's representative also submitted a written brief to the Court prior to the May 2011 Joint Motion. Therein, the Veteran's representative argued that the Board improperly rejected the Veteran's lay statements that he had experienced problems with his knee during and after service because they were not supported by contemporaneous evidence of record. The Veteran's representative also argued that the Board erred when it did not seek clarification from Dr. T. S. regarding his opinions. On VA examination in November 2011, the Veteran reported that he had torn ligaments after he suffered a fall in basic training. He denied having any knee problems prior to active duty. The Veteran reported that he underwent surgery in 1968 at Madigan Hospital for repair of one of the ligaments and spent six weeks in a long-leg cast. He stated that he had experienced continuous problems with his knee since service, which included pain, locking, and giving out. The Veteran reported experiencing pain daily and having flare-ups approximately four to five times per month that included exacerbations and worsening of his symptoms. He ambulated with a cane and knee brace. The Veteran reported the same symptoms bilaterally. On physical examination, knee flexion and extension were five out of five. The Veteran was tender to palpation at his medial joint line and the superior aspect of his patella on both knees. He had crepitus with range of motion but no effusions. The Veteran had an approximately three centimeter oblique incision over his medial and anterior left knee. He had a negative McMurray's examination, and his knee was stable to varus and valgus in 30 and zero degrees of flexion. The Veteran's range of motion was from 10 degrees to 95 degrees, and repetition caused worsening pain but no increase in fatigability, weakness, or instability. X-rays showed early medial compartment degenerative joint disease with subtle narrowing bilaterally. He also had a patella baja on both knees. The VA examiner diagnosed degenerative joint disease of bilateral knees and patella baja, bilateral knees. In rendering his opinion, the VA examiner noted the presumption that a left knee injury pre-existed active duty and observed that the Veteran had surgery, which appeared to be a medial collateral ligament reconstruction. The VA examiner stated that the Veteran's patella baja was not a consequence of any injury. He also opined that the Veteran's symptoms were attributable to degenerative joint disease, which was not particularly advanced beyond what he would expect for someone of the Veteran's age. The VA examiner found that the Veteran's pre-existing patella baja could overload the patellofemoral joint to cause degenerative changes, which seemed to fit the Veteran's symptoms. Because of the radiographic changes and the development of degenerative arthritis, the VA examiner determined the Veteran's current left knee disability was not above and beyond the natural progression of the disease. He opined that it was not "at least as likely as not" that the Veteran's current left knee disability was aggravated by military service. Because of the examination findings, the VA examiner opined that the Veteran could have experienced the same symptoms whether or not he had been in service for three months. In a March 2012 written statement, the Veteran's representative asserted that the Veteran's report of left knee pain due to playing football was actually in reference to playing football during basic training and not to football played prior to active duty. The representative argued that by definition an increase of symptomatology from "stable" to "highly unstable," as noted by the July 1968 examiner, suggested that the medial collateral ligament was at the very least healed to some degree at the time of entrance and accordingly must have been aggravated by service to the point that some or all of the healing had been reversed. In May 2012, per the Board's remand instructions, the Veteran's claim was forwarded to the November 2011 VA examiner for clarification of the previous opinion. The VA examiner repeated his conclusion that the Veteran's current degenerative joint disease was not more advanced than he would expect for the natural history of that disorder. He also found that the Veteran had radiographic features that could predispose him to patellofemoral changes which were radiographically present at bilateral knees. The VA examiner opined that the Veteran's symptomatology was largely originating from this region, and therefore, he did not find that it was above or beyond what he would consider the natural progression of his knee condition. As a result, he found it "less likely as it is not" that the Veteran's left knee disability was aggravated by military service and determined that his current knee condition may have existed in its current form regardless of service. In July 2012, the Veteran's claim was forwarded to an additional VA examiner for review. The VA examiner recorded that he had reviewed the entire claims file as well as all of the Veteran's service treatment records and post-service treatment records. The VA examiner stated he would have to disagree with Dr. T. S.'s assessment because the evidence of record included documentation that the Veteran had a football injury to his knee prior to active duty. He also observed that Dr. T. S. did not have access to the Veteran's entire medical record and made no mention of the medical record or any imaging modalities. Rather, Dr. T. S. appears to have based his assessment solely on the Veteran's testimony of an injury in basic training. The VA examiner noted that he had reviewed the Veteran's x-rays from February 2011 and October 2011. He observed that the Veteran had some mild patellofemoral arthritic changes and mild tricompartmental disease. The VA examiner found it particularly notable that the Veteran's left knee and right knee were almost identical in terms of the degree of arthritis in the knee; he stated he would expect that if the Veteran had a multi-ligamentous knee injury and had posttraumatic arthritis there would be much more advanced disease on the left. The VA examiner also reviewed the March 2012 MRI scan and found that the Veteran had a degenerative meniscal tear common in a 61-year old man with some moderate arthritis in the knee. He stated this would certainly explain the symptoms of catching and locking. Giving the x-ray findings, the MRI scan, and the clear documentation, to include the July 1968 service treatment record noting a history of intermittent locking and pain of the left knee at age 14, the VA examiner opined that the Veteran's left knee disability was not aggravated by active duty. He determined that the Veteran's current knee condition may exist in its current form regardless of military service. The VA examiner noted that he had reviewed the Veteran's lay statements regarding a direct correlation between an injury sustained in active duty and his current knee problems. However, the VA examiner did not find any evidence in the record to support the Veteran's contentions. As noted above, pursuant to the Court's Memorandum Decision, the Board finds that a left knee disorder pre-existed active duty, and as a result, the remaining questions are whether the pre-existing left knee disorder was aggravated during active service and if so, whether his current left knee disability is the result of that aggravation. 38 U.S.C.A. § 1110, 1153; 38 C.F.R. § 3.306. Here, the service treatment records establish that the Veteran's pre-existing left knee disorder, which was stable at entrance, became symptomatic in service during basic training, and this resulted in his being sent for an orthopedic consult and ultimately separated from active service. The next question is whether the symptoms were merely temporary or intermittent flare-ups of symptoms of the preexisting condition or whether they represented a worsening of the underlying condition. As noted above, temporary or intermittent flare-ups of symptoms of a preexisting condition, alone, do not constitute sufficient evidence for a non-combat veteran to show increased disability for the purposes of determinations of service connection based on aggravation under section 1153 unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Although examiners in service found the pre-existing condition disqualifying for the rigors of military service such that it warranted separation, service treatment records suggest that the examiners at that time thought the increase in severity to be a flare up of symptoms as they clearly determined that the preexisting condition had not been aggravated. Support for their determination comes four months after separation from service from the December 1968 VA examiner who found the Veteran's left knee was normal. X-ray findings were normal, and comparative circumference measurements of the thighs did not indicate the existence of a serious disease of the left knee. The diagnosis was a healed laceration of the left knee with a healed scar on the upper tibia. Thus, there is affirmative evidence demonstrating the Veteran's left knee was healed and normal within four months after separation from service. In addition, the December 1968 VA examination shows the Veteran did not seek medical advice or treatment for his left knee immediately after separation from service, despite his in-service complaints of chronic pain. Furthermore, the evidence of record does not indicate that the Veteran sought treatment for his left knee disability until the 1990's, over 20 years after his separation from service. A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred or aggravated in service such that it resulted in chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Thus, the persuasive medical evidence reflects that the Veteran's pre-existing left knee disorder underwent a flare-up of symptoms during active duty but that there was no increase in the severity of the underlying condition. Davis, 276 F. 3d at 1346-47; Hunt, 1 Vet. App. at 297. Because there was no increase in the severity of the underlying condition, the presumption of aggravation does not attach in this case. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Accordingly, the Board need not rebut the presumption with clear and unmistakable evidence that the pre-existing knee condition was not aggravated during active service, but rather the Board must review whether the pre-existing knee condition was aggravated in service under the preponderance of the evidence standard. Thus, the question is whether there is an approximate balance of positive and negative evidence regarding whether the knee condition was aggravated; if so, the benefit of the doubt shall be given to the Veteran. 38 U.S.C.A. § 5107(b). See Gilbert, 1 Vet. App. at 54. Concerning the question of aggravation, the Board finds that the July 2012 VA examiner's opinion, in conjunction with the November 2011 VA examination findings, is more probative than Dr. T. S.'s private medical opinions and the Veteran's lay assertions with regard to whether a pre-existing left knee disorder was aggravated by active duty. First, it is notable that Dr. T. S. did not appear to have access to the Veteran's entire claims file. Additionally, Dr. T. S.'s July 2003 and January 2004 opinions did not address the specific question at issue because neither acknowledged the presumption of a pre-existing left knee disorder. As a result, these opinions carry no significant value with regard to the pertinent question on appeal. Concerning the February 2004 medical opinion, Dr. T. S. opined that it was "at least and likely as not" that the Veteran would have an injury as the result of his service-connected tear of the medial meniscus. He also found that the Veteran's knee condition may be the result of the aggravation of his meniscus tear during basic training. In this respect, the Board notes that Dr. T. S. continually references only an injury incurred in basic training--that of a tear of the medial meniscus. Although he states that the Veteran's current left knee condition may be the result of in-service aggravation, he cites the initial injury as that of the meniscus tear. Dr. T. S. does not appear to consider the issue of aggravation of an injury incurred prior to active duty, which has been established by the record and ordered by the Court. Furthermore, the Board affords little probative value to the February 2004 medical opinion because it is too speculative upon which to base a grant of service connection. Specifically, the use of the word "may" in the opinion makes the opinion speculative in nature. See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus); see also Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by physician is too speculative). Additionally, Dr. T. S. does not provide a rationale for the opinion and does not account for prior clinical findings. In this respect, Dr. T. S. does not address the December 1968 VA examination findings, which did not demonstrate any objective medical findings concerning a left knee disorder. Rather, he reports that the Veteran had persistent and continual problems since active duty. Additionally, Dr. T. S. found that there was no indication that the Veteran's current scar pre-existed service; however, the Veteran's service treatment records demonstrate the Veteran's reports of having multiple stitches in his left knee prior to active duty. Moreover, the December 1968 VA examination shows that prior to active duty, the Veteran had sustained a cut on the inner side of his left upper tibia which had left the residual scar. The value of a physician's statement is dependent, in part, upon the extent to which it reflects clinical data or other rationale to support his opinion. Bloom v. West, 12 Vet. App. 185, 187 (1999). Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. The Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of a particular case in order to reach the conclusion submitted in the medical opinion. See Nieves-Rodriguez, 22 Vet. App. 295. Because Dr. T. S. did not address all of the relevant facts and did not provide an opinion based on pre-existing left knee injury, the Board finds the February 2004 medical opinion carries little probative weight. Conversely, the evidence of record demonstrates that the July 2012 examiner reviewed the Veteran's claims file, to include all of the Veteran's service treatment records and post-service medical records, considered the Veteran's statements and the private medical opinions, and provided an opinion with supporting rationale. See Nieves-Rodriguez, 22 Vet. App. at 303 (noting that it is what an examiner learns from the claims file for use in forming the expert opinion that matters and that, when the Board uses facts obtained from one opinion over another, it is incumbent upon the Board to point out those facts and explain why they were necessary or important in forming the appropriate medical judgment). The July 2012 VA examiner cited to specific service treatment records and post-service treatment records in support of his opinion. He noted the documentation indicating the Veteran had a football injury prior to active duty. He highlighted the findings from the February 2011 and October 2011 x-ray examinations, which showed that the Veteran's left and right knees were almost identical in terms of the degree of arthritis in the knee, and opined that if the Veteran had incurred a multi-ligamentous knee injury in service, there would be evidence of posttraumatic arthritis and the disease would be much more advanced. He also opined that the March 2012 MRI scan showed degenerative meniscal tear common to someone the Veteran's age with moderate arthritis in the knee. Finally, the July 2012 VA examiner considered the Veteran's statements that his current knee condition was directly related to an in-service injury; however, he did not find any evidence in the record to support the Veteran's assertions. Because the July 2012 VA examiner reviewed the entire claims file, to include the Veteran's lay statements, and provided supporting rationale for the conclusions reached, the Board finds the opinion is entitled to greater probative value than the three medical opinions provided by Dr. T. S. The Board acknowledges the statements provided by the Veteran, his buddy, and the Veteran's representative. Indeed, the Veteran is competent to describe his symptoms during and after service, and the Veteran's buddy is competent to describe his observations of the Veteran's symptoms. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Although the Veteran's statements are considered competent, the Board does not find them to be credible evidence that a pre-existing left knee disorder was aggravated by active duty. First, the Veteran has provided unclear statements as to the specific injury in service that supposedly aggravated his pre-existing left knee disorder. In fact, throughout the pendency of the appeal, the Veteran has provided only a vague recollection of an in-service injury; the November 2011 examination findings demonstrate the Veteran's report that he had "suffered a fall" in basic training. More often than not, the Veteran has stated that he could not remember the nature of the injury or the circumstances. Additionally, the Board takes note of the Veteran's contradictory statements regarding his scar. The Veteran's service treatment records indicate that he reported having had stitches in his leg beneath his "wounded knee" prior to active duty. The December 1968 VA examination demonstrates the Veteran reported sustaining a cut on the inner side of his left upper tibia which had left the resulting scar. However, in April 2001 the Veteran stated that he did not remember any other cause for the scar other than his reported in-service injury. Further, the Veteran's statements regarding continuity of symptomatology have been inconsistent. Although the Veteran reported to Dr. T. S. that he has had continuous problems since service, the May 1995 private treatment record shows the Veteran denied any problems until he began to look for work. Moreover, the evidence of record demonstrates the Veteran did not seek medical treatment for his left knee disability until the 1990's. Additionally, the Social Security Administration noted in its April 2004 decision that a non-examining state agency expert, who had reviewed the VA and consultative examiners' reports in July 2003, found that both evaluating physicians hinted at poor compliance and inconsistencies or malingering. The expert concluded that the Veteran significantly exaggerated his symptoms and limitations. While these statements do not pertain to the actual issue of aggravation, they do detract from the Veteran's credibility. See Caluza v. Brown, 7 Vet. App. 498, 51 (1995) ("The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character."), citing State v. Asbury, 415 S.E.2d 891, 895 (W. Va. 1992); see also Burns v. HHS, 3 F.3d 415, 417 (Fed. Cir. 1993) (testimony was impeached by witness' "inconsistent affidavits" and "expressed recognition of the difficulties of remembering specific dates of events that happened . . . long ago"); Mings v. Department of Justice, 813 F.2d 384, 389 (Fed. Cir. 1987) (impeachment by testimony which was inconsistent with prior written statements). As a result, the Board finds that the evidence contemporaneous with service is more probative and credible than the Veteran's current assertions. Contemporaneous evidence has greater probative value than history as reported by the Veteran. See Curry v. Brown, 7 Vet. App. 59, 68 (1994); see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995). Here, the Board finds the July 2012 VA medical examiner's opinion, in connection with the November 2011 VA examination findings, more probative than the private medical opinions and lay statements of record with regard to the issue of aggravation. As a result, the probative evidence of record does not show that the Veteran's pre-existing left knee disorder was aggravated during service for the purpose of establishing entitlement to service connection under VA regulations. Accordingly, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for a left knee disorder. For the reasons stated above, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for residuals of a left knee injury with healed lacerations. Accordingly, the benefit of the doubt doctrine is not for application, and the benefit sought on appeal must be denied. See generally Gilbert, 1 Vet. App. at 53. ORDER Entitlement to service connection for residuals of a left knee injury with healed lacerations is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs