Citation Nr: 1324955 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 99-15 989A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability, to include as secondary to a right knee disability. REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R.N. Poulson, Counsel INTRODUCTION The Veteran served on active duty in the Air Force from September 1978 to September 1982. He served in the Air National Guard from November 1982 to October 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 1998 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In September 1999, the Veteran testified at a hearing before a Decision Review Officer (DRO). A transcript of the hearing is associated with the claims folder. The Board remanded this case in April 2001 and June 2003 for additional development. In August 2005, the Board denied the Veteran's claims for service connection for left and right knee disabilities. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In December 2007, the Court issued a judgment that vacated that portion of the August 2005 decision that denied service connection for right and left knee disabilities, and remanded the issues for readjudication consistent with the Court's Memorandum Decision. In May 2012, the Board remanded the case so that the agency of original jurisdiction (AOJ) could consider a December 2011 private opinion from a nurse consultant. A review of the record shows that the AOJ has complied with all remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). At the beginning of the appeal, the Veteran was represented by the Veterans of Foreign Wars (VFW). In a March 2008 VA Form 21-22a, the Veteran appointed attorney Daniel G. Krasnegor as his representative, thereby revoking the earlier power of attorney. FINDING OF FACT The Veteran's current right and left knee disabilities are not related to any event, injury, or disease in service, and arthritis was not manifest to any degree within one year after discharge from service. CONCLUSIONS OF LAW 1. A right knee disability was not incurred in the Veteran's active duty service; nor may arthritis be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 2. A left knee disability was not incurred in the Veteran's active duty service; nor may arthritis be presumed. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS I. Notice and Assistance Under the Veterans Claims Assistance Act (VCAA) of 2000, codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Court's decision in Pelegrini v. Principi, 17 Vet. App. 412 (2004), held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. This decision has since been replaced by Pelegrini v. Principi, 18 Vet. App. 112 (2004), in which the Court continued to recognize that typically a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. Here, a June 2003 letter complied with VA's duty to notify the Veteran with regards to the service connection issues addressed herein. Specifically, this letter apprised the Veteran of what the evidence must show to establish entitlement to the benefits, what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. Although this notice was delivered after the initial denial of the claims, the AOJ subsequently readjudicated the claims based on all the evidence, most recently in January 2013. Thus, the Veteran was not precluded from participating effectively in the processing of his claims and the late notice did not affect the essential fairness of the decision. The VCAA letter has clearly advised the Veteran of the evidence necessary to substantiate his claims. As will be discussed below, the Board has determined that service connection is not warranted for the claimed knee disabilities, thus any question as to the appropriate disability rating and effective date is moot, and there can be no failure to notify prejudice to the Veteran. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board also finds that VA has complied with its duty to assist the Veteran in the development of the claims decided herein, to include substantial compliance with the April 2001, June 2003, and May 2012 Remands. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The evidence of record contains the Veteran's service treatment records (STRs), private treatment records, and VA outpatient treatment records. There is no indication of relevant, outstanding records which would support the Veteran's claim. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1)-(3). The Board notes that the claims file does not include STRs from the Veteran's National Guard service. Shortly after he filed his claim for service connection, the RO requested STRs from the Veteran's National Guard service. In July 1998, the RO received STRs from the Veteran's active service period, which included 1982 and 1986 examinations from his National Guard service. In March 2002, the RO requested all STRs from the Veteran's National Guard unit. A negative response was received later that month. In August 2002, the RO requested the Veteran's National Guard STRs from the National Personnel Records Center (NPRC)'s Personnel Information Exchange System (PIES). However, in a PIES response dated later that month, the NPRC indicated that it did not have the requested STRs, and concluded that the records either did not exist or that further efforts to locate the records at NPRC would be futile. The RO made an additional attempt to obtain the National Guard STRs. However, later that month the RO received an identical response from the NPRC indicating it did not have the records. In any event, the Board notes that the Veteran is not claiming that a disability occurred during National Guard service. See July 1998 Statement; see also Hearing Transcript at 9, 12, and 16. The Board also acknowledges that the records from the Veteran's 2001 left knee arthroscopy are not in the claims file. However, a remand to obtain those records is unnecessary because, as discussed below, current disability has been established. Thus, the Board's proceeding with this case will not prejudice the Veteran. The Veteran's attorney indicates that certain records are missing from the claims file. Specifically, the attorney contends that no search has been conducted for any medical clinic records. See October 2010 Statement. The Board notes that the claims file does not contain STRs from Barksdale Air Force Base in Louisiana, where the Veteran contends he received medical treatment for his knee injuries. In August 2004, the RO requested clinical records in one-year increments from the Barksdale AFB Medical Center for the period from January 1979 to December 1982. In a PIES response dated in November 2004, the NPRC indicated that it did not have the records. Simply put, the Veteran's attorney is wrong. When a veteran's records have been determined to have been destroyed, or are missing, VA has an obligation to search for alternative records that might support the veteran's case. Cuevas v. Principi, 3 Vet. App. 542 (1992). Here, VA met that obligation by making multiple attempts to secure National Guard STRs from a variety of sources. VA also attempted to obtain clinical treatment records from a military treatment facility. The Veteran has been duly informed of the unavailability of both records. See November 2002 and April 2005 Supplemental Statements of the Case. No other alternative sources of records have been identified. In any event, the Veteran testified that he did not receive any treatment for his knees from the National Guard Unit. See Hearing Transcript at 11. Thus, the Board finds that any additional efforts to obtain such records would be futile. The Veteran underwent VA examinations in August 1998 and July 2009 pertaining to his service connection claims. In that connection, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The August 1998 report contains no nexus opinion. As noted below, the Board finds that the July 2009 VA opinion is adequate, as it was predicated on consideration of all of the pertinent evidence of record, to include statements regarding the incidents that allegedly led to the development of the Veteran's knee disabilities, and documents that the examiner conducted a full examination of the Veteran, thoroughly reviewed of the claims file, and fully understood the questions posed by the AOJ. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the claims on appeal has been met. See 38 C.F.R. § 3.159(c)(4). The Veteran was provided an opportunity to set forth his contentions during the hearing before a decision review officer (DRO) in September 1999. In Bryant v. Shinseki, 23 Vet. App. 488, the Court held that 38 C.F.R. § 3.103(c)(2) requires that the hearing officer who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the September 1999 hearing, the DRO identified the issues on appeal. Subsequently, the Veteran submitted additional treatment records from his personal physician that he had identified during the hearing. The Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for benefits. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the RO hearing. As such, the Board finds that, consistent with Bryant, the DRO 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. For all the foregoing reasons, the Board concludes that VA's duties to the Veteran have been fulfilled with respect to the issues on appeal. II. Analysis Service connection may be established on direct basis for a disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Alternatively, service connection may be granted on a presumptive basis for a chronic disease, such as arthritis, which manifests to a compensable degree within the initial post-service year. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of 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 present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Until recently, the second and third elements of Hickson could be met through a showing of continuity of symptomatology, which could be established under certain circumstances through lay evidence. See 38 C.F.R. § 3.303(b) (2012). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has now clarified that the theory of continuity of symptomatology applies only to diseases recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In other words, that theory may only serve as a path to service connection for diseases that fall within the presumptive provisions outlined above. Such diseases include degenerative arthritis. 38 C.F.R. § 3.309(a) (2012). Accordingly, the Board will consider whether to grant the Veteran's claim based on continuity of symptomatology as well as the traditional Hickson elements. See 38 C.F.R. § 3.303(b); Hickson, 12 Vet. App. at 253. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Additionally, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Here, the Veteran believes that his currently diagnosed knee disabilities resulted from in-service injuries. His representatives have stated that he continued to suffer from bilateral knee pain after service. See, e.g., April 2000 VA Form 1-646. Alternatively, the Veteran maintains that his left knee disability is related to his right knee disability. Specifically, he contends that his private doctor told him that his left knee disability is the result of overcompensating for his right knee disability. STRs reflect that the Veteran had a lipoma removed from his left knee in December 1981. Nine days later the area was noted to be swollen, tender, and infected. Subsequent evaluation noted that there was no more pus, and that the area was "healing o.k." STRs do not contain any complaints or findings related to the Veteran's right knee. Although the December 19, 1981 record indicates that the right knee was aspirated, it seems that this statement is a typographical error, based on reviewing the STRs in their entirety. See also July 2009 VA Examination Report and July 2010 Addendum (noting that this reference to the Veteran's right knee was "obviously an error"). There is no active duty separation examination in the claims file. A National Guard enlistment examination in November 1982 and a periodic examination in November 1986 noted normal lower extremities and musculoskeletal examinations. The Veteran denied history of a trick or locked knee on both accompanying medical history reports. A private medical record dated in April 1985 noted a complaint of right knee pain; the impression was ligamentous strain. In June 1987, chondromalacia of the right knee was noted. In July 1987, the Veteran was seen with complaints of a three month history of right knee pain. He underwent arthroscopic surgery for probable tear of lateral meniscus. The surgery revealed the meniscus to be intact. A partial synovectomy was performed. In June 1991, the Veteran complained of left knee pain which he said had been present for "twelve to fifteen years." X-rays showed minor osteoarthritic changes. Arthroscopy was performed is July 1991. There was a complex tear of the posterior horn of the lateral meniscus, and an oblique tear of the posterior horn of the medial meniscus. Grade I degenerative joint disease was noted in the medial compartment. An August 1991 follow-up noted arthritis of the left knee. July 1998 X-rays revealed degenerative joint disease in both knees. A VA examination was conducted in October 1998. The Veteran complained of some pain and swelling in the right knee, but he did not recall an injury. He reported having twisted his left knee during service when he stepped in a hole. X-rays of the left knee revealed a minimal amount of narrowing of the femoral tibial joint space medially consistent with early arthritic disease. X-rays of the right knee revealed slight enlongation of the spines, but no narrowing of the articular cartilage or ostephyte formation. The diagnoses included mild osteoarthritis, left knee. The examiner did not diagnose a right knee disability. A July 1999 private treatment record shows that the Veteran was treated for left knee pain and swelling. The diagnosis was degenerative joint disease, knees. In August 1999, the Veteran reported a "long history [of knee pain] since [illegible]." He was diagnosed with post-traumatic degenerative joint disease. During the September 1999 DRO hearing, the Veteran indicated that he was unsure as to when he first sought medical treatment for his right knee after discharge from active service. Hearing Transcript at 10. In a statement dated the following day, the Veteran indicated that the cysts in his left knee were discovered during the course of treatment for a left knee injury. A statement dated in September 1999 from T.G .T., M.D., noted that the Veteran was under the physician's care. The doThe doctor wrote: "Based on his medical and military records reviewed by me, it is certainly possible that the injuries sustained to his . . . knees are secondary to required activities during his active military service." In June 2001, the Veteran gave a history of numerous knee injuries while in the Air Force. He complained of pain, noise, slipping, wobbling, swelling, grinding, stiffness, and locking of both knees. He reported that this problem "began suddenly, more than one year ago." He gave a specific onset date of January 1, 1980. X-rays revealed Stage IV medial arthritis. The diagnosis was degenerative arthritis, both knees. The Veteran subsequently underwent a left knee arthroscopy in 2001. The Board notes that these records are not in the claims file. Upon follow-up in February 2002, he was still having "a little pain "in the left knee. In June 2002, it was noted that there was "just bone on bone." In October 2002, it was noted that the Veteran had arthritic changes in his left knee. He also complained of right knee pain, but indicated that it was not as bad as the left knee pain. He was diagnosed with medial compartment arthritis of the left knee. A May 2006 MRI of the left knee revealed extensive medial and lateral meniscal tears; cruciate and extensive osteoarthritis. The Veteran subsequently underwent a total knee replacement (TKR) in 2007. In March 2009, the Veteran was evaluated for rheumatoid arthritis (RA). At that time, he reported a 20-year history of severe pain and stiffness in his feet and entire body. The Veteran was diagnosed with RA in April 2009; the doctor indicated that it involved the right knee. The Veteran submitted to a July 2009 VA joints examination. He reiterated the history of reportedly twisting his left knee by stepping in a hole during service. This knee had been "intermittently symptomatic" over the years. He still had pain despite having had a TKR. He reportedly injured his right knee in 1979. The Veteran indicated that he had been diagnosed with RA in 2008. X-rays revealed left knee prosthesis and right knee degenerative joint disease. The diagnoses included status post left TKR and post-operative arthroscopy of the left knee, degenerative joint disease. The examiner conducted an "extensive review" of the claims file, to include STRs and private medical records, and opined that there "is a less than 50% probability" that the Veteran's knee disabilities are "the direct and proximate result of any incident or occurrence in the military." He explained that the right knee reference in the December 1981 STR was an error. In a July 2010 addendum, the VA examiner reviewed additional private treatment records and indicated that his opinion remained unchanged. He stated that his opinion was "[b]ased upon my training, judgment, past experience and extensive review of record." He reiterated that the December 1981 STR reference to the Veteran's right knee was a mistake. A December 2010 VA treatment record confirms that the Veteran has been diagnosed with RA. A March 2011 correspondence from R.S., M.D., indicates that he had followed the Veteran since 2003, and that the Veteran had reportedly sustained injuries to his knees while in service. He stated that the condition of the Veteran's knees had progressed to the point of requiring a TKR on the left and arthroscopic surgery on the right. He wrote: "This comes from review of his old records and from review of the records that I have been able to go over with him through his frequent visits with me and other physicians." In June 2011, the Veteran's representative submitted an opinion from K.C., a legal nurse consultant. She reviewed the claims file and determined that the first documented arthritis-related complaint occurred in 1979. She noted that the Veteran experienced "an unusually prolonged recovery period" after spraining his right ankle in 1979. The nurse explained that in patients with RA, "trauma or over-use of a joint can cause an autoimmune-mediated process that persists much longer than a typical localized inflammatory response." She stated that RA is a disease with alternating flares and remissions of symptoms. She commented that the Veteran's first documented complaint of right knee pain occurred in 1985. The nurse noted that "there is no way to determine how long the inflammation had been present." However, she opined that the onset of the left knee symptoms was in 1979 or earlier based on the fact that, in 1991, the Veteran had reported an onset date of 12-15 years earlier. The nurse acknowledged that the Veteran had denied any joint pain or swelling on the National Guard examination reports, but stated "it is likely that he did not check it because of an absence of swelling." She explained that swelling can be "difficult to appreciate in chronic inflammation of joints." She went on to find that the Veteran's verbal complaints "certainly contradict any notion that he did not have joint pain prior to 1982 and 1986." (Emphasis in original). The nurse also opined that the degree of hypertrophy and tissue damage to the Veteran's left knee in 1991 "suggests to me that the inflammatory process had been ongoing, on a recurrent basis, for quite some time." She opined that the Veteran's clinical condition "represents the effects of long-standing, untreated rheumatoid arthritis that was as likely as not, present during his years of active duty" and that "the required activities of service more than likely contributed to and exacerbated the condition of his knees." (Emphasis in original). In a December 2011 addendum, K.C. indicated that her experience included 12 years as a critical care nurse and 14 years as a legal nurse consultant. She stated that she had reviewed the July 2009 opinion and July 2010 addendum from the VA examiner. She accused the VA examiner of taking the medical records "at face value" and noted that his opinion said nothing about the possible implications RA has on the etiology of the Veteran's knee problems. She noted that while the examiner "accurately quotes verbatim [] various facts from the records, "he fails to consider what is missing from the service medical records." (Emphasis in original). She noted that the absence of reported complaints for several years at a time is not surprising because some people with RA have long periods of remission. She also stated that men are often diagnosed later than women because they tend to downplay their symptoms, and that "[t]his may help to explain why [the Veteran's] medical records do not reflect numerous complaints" during service. In support of her addendum opinion, K.C. included links to WebMD articles about RA. The Court has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discussed generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated medical opinion. Sack v. West, 11 Vet. App. 314 (1998). The Board has reviewed the articles, which discuss the symptoms of RA and the incidence of RA in men. These articles, however, do not address the facts of the Veteran's specific case. Instead, the articles establish that RA is a chronic disease that can involve different parts of the body and long period of remission. The articles also note that men are often diagnosed later than women because "they tend to downplay their symptoms." The Board finds that the medical articles submitted by K.C. are insufficient to establish the required medical nexus opinions for causation. In a December 2012 addendum, the VA examiner reviewed K.C.'s June 2011 and December 2011statements and concluded that they "mostly represent conjecture, speculation and possibilities rather than medical probability." He wrote: "I think it is less likely as not that so many physicians/surgeons would have missed a diagnosis of RA existing as far back into the past as the statements of [K.C.] imply." He opined that "the preponderance of the MER does not support the contentions of [K.C.]" Also of record are several lay statements from the Veteran's friends that describe his physical problems. As the evidence of record fails to establish any clinical manifestations of right or left knee arthritis within the applicable time period, the criteria for presumptive service connection on the basis of a chronic disease have not been satisfied. With respect to service connection on a nonpresumptive basis, the Board observes that the Veteran's current knee diagnoses are not in dispute. Indeed, VA and private providers diagnosed degenerative arthritis by X-ray during the appeal period. The Board notes that the Veteran underwent a left total knee replacement in 2001. However, the objective record shows no orthopedic injury to either of the Veteran's knees during service and no complaints of right knee pain during service. He had a lipoma removed from the left knee in 1981, however, no residuals of that procedure are currently shown. As a result of the presence of STRs tending to dispute his allegations, the Veteran's reports of in-service knee injury or pain are not considered credible, and are therefore not entitled to much weight. With regard to the medical opinions of record, where the Board is presented with conflicting medical evidence, it is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). In this regard, the Board notes that the Federal Circuit and the Court have both specifically rejected the "treating physician rule." See White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001). Instead, the Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one medical professional's opinion over another, depending on factors such as reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. 444, 448-9 (2000). In some cases, the physician's special qualifications or expertise in the relevant medical specialty or lack thereof may be a factor. In every case, the Board must support its conclusion with an adequate statement of its reasoning of why it found one medical opinion more persuasive than the other. The nurse consultant and the July 2009 VA examiner each addressed the Veteran's contentions of how he incurred his knee disabilities. Each also thoroughly reviewed the medical history with respect to each knee since discharge from active service. Both clinicians addressed the current diagnoses referable to the Veteran's knees. However, K.C.'s opinion is speculative in nature. A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). The nurse attributes the Veteran's failure to report knee pain during active service to a remission of (undiagnosed) RA and/or his tendency as a man to downplay symptoms. She concludes that the Veteran had RA during service based, in part, on his reported onset date of knee pain. She states that the condition was only recently diagnosed because it is a difficult disease to diagnose and less prevalent in men than women. However, the Board notes that both knees were extensively evaluated prior to and during the appeal period. The VA examiner's conclusion, which is summarized in the July 2009 VA examination report with July 2010 and December 2012 addendums, that it is unlikely that numerous physicians and surgeons overlooked such a diagnosis is a logical one. The Board also notes that while K.C.'s opinion cites to several medical articles, none are attached to the opinion. K.C. is a critical care nurse and competent to discuss the etiology of disability, but is not shown to be equally or more competent than the VA physician. Similarly, the Board finds that the September 1999 opinion of Dr. T.G.T. is entitled to little probative value. Although it appears that he reviewed the Veteran's STRs, the opinion is speculative and contains no rationale. He merely opined it is "possible" that the Veteran's service-related knee injuries are secondary to activities required during his active service. Also, it appears that he based his opinion on an incorrect factual basis since, as discussed above, the STRs contain no evidence of any knee disability. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative). In contrast, the VA examiner opined in July 2009, July 2010, and December 2012 that the Veteran's knee disabilities are not related to service. He conducted an extensive review of the claims file, discussed the evidence (to include K.C.'s opinion and addendum), examined the Veteran, and provided a rationale for his opinion. There is no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact. Moreover, the Board considers it significant that the December 2012 addendum constituted the most recent additions to the claims file. Accordingly, the examiner took into account the most up-to-date evidence in the file, which includes the addendum from the nurse-consultant. Therefore, this opinion is highly probative. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (the opinion of a physician that is based on a review of the entire record is of greater probative value than an opinion based solely on the veteran's reported history). The Veteran's attorney has argued that the VA examiner did not address the 1985 private treatment record. The Board cannot speculate as to whether the 1985 private treatment record was appropriately considered in offering the opinion. The fact remains, however, that the VA examiner was fully aware of the Veteran's in-service and post-service medical history based on a review of the record. The Veteran's attorney also maintains that the December 19, 1991 STR is evidence of medical treatment for a right knee condition. In the alternative, he argues that the VA examiner failed to render an opinion as to whether the aspiration of the left knee during service is related to the Veteran's current left knee disability. However, the attorney is not competent to comment on the import of a particular treatment record. The VA examiner read that record in context with the other entries from that time period, which concern left knee treatment only, and opined that it is a typographical error. This seems not only plausible, but likely, considering the context. Furthermore, he concluded that the Veteran's current left knee disability is not the direct and proximate result of any incident that occurred during service, which includes any left knee treatment. The Veteran and his friends genuinely believe that his knee disabilities were incurred in service. Their statements regarding the symptoms of pain are competent, regardless of the lack of contemporaneous medical evidence. However, they have not shown that they have the expertise to comment on a medically complex issue, such as the nature and etiology of the Veteran's degenerative arthritis of the knees. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 Fed. Cir. 2007). As such, the relationship, if any, which exists between those disorders and the Veteran's service is a matter that requires medical expertise to resolve, especially where, as here, it was first manifested many years after the Veteran's discharge from active service. In contrast, such expertise has been demonstrated by the VA examiner, whose negative nexus opinion is deemed probative for the reasons summarized above. Furthermore, the Board considers it significant that, despite disagreeing with the VA examiner, the Veteran has not alleged that this examiner was unqualified to render etiological findings in connection with this appeal. Therefore, the Board finds that the Veteran's own views in this regard are outweighed by the VA examiner's negative nexus opinion. The Board's analysis does not end here as it must now consider whether an alternative to nexus has been presented through continuity of symptomatology. See 38 C.F.R. § 3.303(b) (2012). The Veteran has reported a continuity of knee symptomatology dating back to his years in service. However, there is a lack of documented complaints or clinical findings for many years after he left active service. The 1982 and 1986 National Guard examinations did not demonstrate any knee pathology. In the Reports of Medial History, the Veteran denied having or having had trick or locked knee. It seems reasonable he would have mentioned knee problems at this time, since he did report other physical problems. The first documented medical report of a right knee disability came in April 1985. Right knee arthritis was not diagnosed until 1998, sixteen years after the Veteran's separation from active duty. Left knee arthritis was first diagnosed in 1991, nearly nine years following the Veteran's separation from active duty. With respect to negative evidence, the fact that there were no records of any complaints or treatment involving the Veteran's knees for many years weighs against the claim. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (it was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints). In light of these factors, the Veteran's current statements to the effect that he has experienced continuous symptomatology since active service, while competent, are not deemed to be credible. Therefore, the absence of documented treatment is found to be more probative than the Veteran's competent statements. Accordingly, continuity of symptomatology is not established by either the competent evidence or the Veteran's own statements. Because service connection has not been granted for a right knee disability, any further consideration of the issue of entitlement to service connection for left knee disability as secondary to a service-connected right knee disability is moot. The preponderance of the evidence is against the service connection claims for right and left knee disabilities; there is no doubt to be resolved; and service connection is not warranted. Gilbert, 1 Vet. App. at 57-58. ORDER Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs