Citation Nr: 1324986 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 07-26 350 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a bilateral hip disorder, to include as secondary to service-connected patellofemoral arthritis of the right knee. 2. Entitlement to service connection for a low back disorder, to include as secondary to service-connected patellofemoral arthritis of the right knee. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD H. Yoo, Counsel INTRODUCTION The Veteran served on active duty from November 1975 to November 1988. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a January 2006 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran filed a notice of disagreement (NOD) with that determination in May 2006, and timely perfected his appeal in August 2007. The Veteran was afforded a Travel Board Hearing before a Veterans Law Judge (VLJ) in February 2011. A written transcript of this hearing was prepared and incorporated into the evidence of record. Although that Veterans Law Judge has since retired from the Board, the Veteran did not respond to a January 2013 letter informing him of this retirement and giving him the opportunity to request that another hearing before a Veterans Law Judge be scheduled. In May 2011 and May 2013, the Board remanded this matter for further development. The Board is satisfied that there has been substantial compliance with the remand directives and the Board may proceed with review. See Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the above claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. FINDINGS OF FACT 1. The Veteran did not manifest a bilateral hip disorder in service or arthritis of the hips to a compensable degree within one year after discharge from service, and it is not otherwise shown to be associated with service, to include secondary to his service-connected patellofemoral arthritis of the right knee. 2. The Veteran did not manifest a low back disorder in service or arthritis of the low back to a compensable degree within one year after discharge from service, and it is not otherwise shown to be associated with service, to include secondary to his service-connected patellofemoral arthritis of the right knee. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for bilateral hip disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for establishing service connection for a low back disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act (VCAA) With respect to the appellant's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and 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. The notice requirements described above apply to all five elements of a service connection claim: (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In October 2005 and November 2009, the agency of original jurisdiction (AOJ) provided the notices required by 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the AOJ notified the Veteran of information and evidence necessary to substantiate the claims for service connection; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. The November 2009 letter provided the Veteran with the notice pursuant to Dingess. Although the Veteran was not provided notice of the effective date and disability rating regulations until after the initial adjudication, because service connection has been denied, any question as to the appropriate disability rating or effective date is moot, and there can be no failure-to-notify prejudice to the Veteran. Id. All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (2012) (harmless error). In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claims, as well as the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. The record indicates the VA has unsuccessfully attempted to obtain, to the extent possible, all outstanding private medical records identified by the Veteran. The Veteran has at no time referenced additional outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on a claim, as defined by law. The record indicates that the Veteran was afforded VA examinations in May 2013 pursuant to the Board's Remand. This opinion involved review of the claims file and thorough examinations of the Veteran and the opinion was supported by sufficient rationale. Therefore, the Board finds that the examinations are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claim. Additionally, the Board finds there has been substantial compliance with its October 2011 remand directives. The Board notes that the Court has recently noted that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand.) Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remands. See Stegall, supra, (finding that a remand by the Board confers on the appellant the right to compliance with its remand orders). Therefore, in light of the foregoing, the Board will proceed to review and decide the claims based on the evidence that is of record consistent with 38 C.F.R. § 3.655 (2012). Furthermore, in February 2011 the Veteran testified at a Board hearing at the RO over which a Veterans Law Judge (VLJ) presided. The provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the Board hearing, the VLJ clarified the issues on appeal and inquired as to the etiology and continuity of the Veteran's asserted symptoms. The Veteran was offered an opportunity to ask the undersigned questions regarding his claim. The Board, therefore, concludes that it has fulfilled its duty under Bryant. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). The Veteran has submitted arguments and evidence in support of the appeal. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication is not affected. II. Merits of the Claims The Veteran alleges that he experiences a low back disorder and a bilateral hip disorder secondary to his service-connected patellofemoral arthritis of the right knee. Governing Laws and Regulations Under the laws administered by VA, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 C.F.R. § 3.303(d). Generally, the evidence 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. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004) (citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); Caluza v. Brown, 7 Vet. App. 498, 505 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table)). Service connection may also be granted for chronic disabilities, such as organic disease of the nervous system, if such are shown to have been manifested to a compensable degree within one year after the Veteran was separated from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As an alternative to the nexus requirement, service connection for these chronic disabilities may be established through a showing of continuity of symptomatology since service. 38 C.F.R. § 3.303(b) (2012). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this context, given that arthritis is considered as a chronic disease in 38 C.F.R. § 3.309(a), the provisions of 38 C.F.R. § 3.303(b) do apply to the Veteran's claims. Secondary service connection may be granted for a disability that is proximately due to, or the result of, a service- connected disease or injury. 38 C.F.R. § 3.310(a) (2012). With regard to the matter of establishing service connection for a disability on a secondary basis, the Court has held that there must be evidence sufficient to show that a current disability exists and that the current disability was either caused or aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Additionally, when aggravation of a non-service-connected disability is proximately due to or the result of a service- connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id.; see also 38 C.F.R. § 3.310(b). With regard to a claim for secondary service connection, the record must contain competent evidence that the secondary disability was caused by the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). When determining service connection, all theories of entitlement, direct and secondary, must be considered. Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004). As such the Board will address the Veteran's claims for service connection on both direct and secondary bases. In each case where a veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of such veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's treatment records, and all pertinent medical and lay evidence. See 38 U.S.C.A. § 1154(a) (West 2002 and Supp. 2012). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has rejected the view that competent medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d. 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Factual Background and Analysis Bilateral hip disorder Upon review of the service treatment records, the Board notes that the Veteran's bilateral hip disability was not shown in the service treatment records. Rather, the Veteran does not allege that it was diagnosed during service but that it was secondary to his service-connected patellofemoral arthritis of the right knee. Post-service treatment records indicate the Veteran complained of left hip pain in March 2007. The Veteran was treated with a left hip injection in March 2008. The Veteran was diagnosed with degenerative joint disease of the left hip in July 2009 and underwent a total left hip arthroplasty the same month. No determination regarding the etiology of the left hip disorder was offered at any point during treatment. An x-ray of the left hip taken in April 2011 indicated there was no change in the alignment of the total left hip arthroplasty with no evidence of hardware loosening. Minimal degenerative joint disease in the right hip was seen. In May 2011 the Veteran stated he had no issues with ambulation or bending at the hip. Again, no etiological opinion was provided. In August 2011, the Veteran was afforded a VA examination where a physical examination revealed the Veteran's leg lengths were grossly equal and motor function was 5/5 in all muscle groups in the lower extremities. The range of motion on the left hip was 110 degrees of flexion; 5 degrees of extension; 40 degrees of abduction; 5 degrees of adduction; 30 degrees of internal rotation; 20 degrees of external rotation. The range of motion of the right hip was 115 degrees of flexion; 15 degrees of extension; 45 degrees of abduction; 20 degrees of adduction; 45 degrees of internal rotation; 50 degrees of external rotation. There was no pain, fatigue, weakness, or incoordination with repetitive motion, bilaterally. The examiner noted that there was evidence the Veteran sustained an injury to the left hip causing early degenerative changes in the hip which ultimately led to the total hip arthroplasty. However, there was "no association between the injury to his hip and subsequent arthritis and status post total hip arthroplasty related to his mild patellofemoral syndrome right knee." The examiner opined that there was no evidence of association to his military service. The Board determined in May 2013 that this opinion was inadequate and therefore, the Veteran's claim was remanded for additional development. As a result, the Veteran underwent a new VA examination for the hips in May 2013. The Veteran reported that over the past six months he had pain in his left hip and discomfort when he sits and/or when there is changes in the weather. Regarding his right hip, the Veteran stated the onset occurred a few years ago and he experiences constant pain, stiffness, and worsens with motion and was associated to sharp pain. A physical examination revealed the range of motion for the right hip was 110 degrees flexion and 5 degrees extension. There was no painful motion. The range of motion for the left hip was 100 degrees of flexion with painful motion at 70 degrees, and 5 degrees of extension with pain. The Veteran had no additional limitation in range of motion following repetitive use and no functional loss, bilaterally. Muscle strength was normal, bilaterally, for flexion, abduction, and extension. Upon review of the evidence of record, the Veteran's lay statements, and a physical examination, the VA examiner concluded that the Veteran's current hip disability of bilateral degenerative joint disease and status-post left hip arthroplasty was less likely as not related to any in-service disease, event, or injury or had its onset in service. The examiner stated the onset of the hip condition was in 2007 from labral tear or trauma. The examiner further opined that the Veteran's bilateral hip disability was less likely caused or aggravated by the service-connected patellofemoral arthritis of the right knee. The examiner stated: The [V]eteran states he had [a] fall due [to] his knee. The medical records showed twisting hip injury in 2007 and normal [range of motion] and no instability of the knees[.] The current exam did not show any instability of the knees either. I will consider the etiology of the labral tear was degenerative joint disease secondary to direct trauma to hip as seen in most of the cases. The patellofemoral syndrome is not linked to any hip pathology. [There is] [n]o evidence of instability in [the] knees to cause any condition affecting his gait. No evidence of any aggravation beyond the natural progression caused by knees. Here, the examiner's determination is consistent with the evidence of record. The in-service treatment records revealed no complaint, treatment, or diagnosis of a hip disorder. In addition, none of the post-service treatment records offer an opinion that the Veteran's bilateral hip disorder is related to his military service or secondary to his patellofemoral arthritis of the right knee. The Board, therefore, finds that the May 2013 VA examiner provided a negative nexus with regard to the Veteran's claim for service connection based on a secondary bases. In addition, the only evidence of record in support of the Veteran's claim consists of his own lay statements. The Board finds that the Veteran is not competent to relate his bilateral hip condition to his patellofemoral arthritis of the right knee. Although it is error to categorically reject a non-expert opinion as to etiology, or nexus, not all questions of nexus are subject to non-expert opinion. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Whether a layperson is competent to provide a nexus opinion depends on the facts of the particular case. Here, despite the Veteran's contentions, given the complexity of the particular question of etiology and the fact that a nexus opinion may not be rendered based on personal observation, the Board finds that the Veteran is not competent to opine on the etiology of his bilateral hip disorder. As such, the Board finds that the Veteran is not entitled to service connection a bilateral hip disorder, secondary to his service-connected patellofemoral arthritis of the right knee. In addition, direct service connection must also be denied. There is no evidence of an in-service diagnosis of a bilateral hip disorder and no medical nexus relationship between the currently diagnosed bilateral hip disorder and his active duty service has been shown. Furthermore, as stated above, the first reports of pain his left hip was in the mid-2000s and the Veteran was diagnosed in 2009; over 20 years since separation. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) [noting that it was proper to consider the veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised]; see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) [affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of the claimed condition]. As such, service connection for a bilateral hip disorder is not warranted on a direct basis. Unfortunately, although the Veteran has established that he has been diagnosed with degenerative joint disease of the bilateral hip, the evidence of record does not establish that this condition is the result of a disease or injury in active duty service. In conclusion, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a bilateral hip disorder. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The benefit sought on appeal is accordingly denied. Low back disorder According to the Veteran's in-service treatment records, the Board notes the Veteran had sought treatment on numerous occasions for strain and pain in his low back. In November 1975, the Veteran reported low back pain with no history of trauma. In May 1981, the Veteran reported pain in his back after running. The assessment was muscle spasms and the Veteran was treated with Robaxin. In July 1981, the Veteran was further treated for his back pain. In August 1981, the Veteran reported his back pain had not resolved. In January 1982, the Veteran reported his back pain stemmed from moving generators. The examiner noted it appears the Veteran strained his back. In August 1983, the Veteran sought treatment for flare ups in his back following a long distance drive two months prior. In October 1984, the Veteran reported pain between the scapulas after lifting wall cockers. The first post-service instance of a report of back pain was in January 2003, where the Veteran reported it started the night prior. VA treatment records from 2003 to 2005 indicate the Veteran was treated on several occasions for low back pain without a history of trauma. A December 2005 x-ray of the lumbar spine revealed disc space narrowing at the L5-S1 with vacuum disc phenomenon. Mild hypertrophy and sclerosis of the facet joints of the lower lumbar spine were also noted. There was no evidence of spondylolisthesis. There is no etiological opinion that the Veteran's low back pain was related to his military service or secondary to his service-connected patellofemoral arthritis of the right knee. The Veteran was afforded a VA examination of the spine in May 2007. A physical examination indicated the spine was anatomically normal. He had no muscle spasms, his posture was normal, and had a normal gait. The Veteran was able to rise out of a char without the use of his hands or arms. Range of motion was 90 degrees of flexion and 30 degrees of extension. The Veteran's flexion and extension against force was normal. The Veteran's right and left lateral rotation was 30 degrees. An x-ray revealed mild steopenia, sacralized L5, with disc space narrowing at the L4-5. The assessment was normal lumbosacral spine. The examiner concluded that the Veteran's back problems were not due to his military service. The examiner explained that there was no chronicity as there is no history of complaints and treatment dated from his separation from service in 1988 to the time of this examination. The examiner stated the Veteran reported he was a paratrooper but there was no evidence of this according to his military records. The Veteran's physical examination was essentially normal and the x-rays showed "very minimal degenerative disc changes, which would be normal for someone age 50." The examiner stated there was no evidence the Veteran sustained injury during service which would produce a long-lasting problem. The only instance that he reported injury was a total muscular type which was caused by lifting. The examiner noted this instance resulted in one visit to the clinic and no follow up. The Veteran underwent another VA examination in August 2011 where the examiner acknowledged the Veteran's in-service complaints and treatment for low back pain. However, the examiner noted the last report of low back pain was in October 1984 indicating over four years of active duty service without further complaints regarding his back. The first documented complaint post-service was in 2002. On physical examination the Veteran reported he could not lie flat on his back. He stated in 1981 he had a herniated disc and was in a back brace. He described on and off left leg pain. Repetitive bending or lifting aggravated his back. He reported treatment with physical therapy and a heating pad in the past. He does not use a brace or other aids for his back and described no flare ups or incapacitating events. The Veteran had 90 degrees of flexion, without pain, fatigue, weakness, or incoordination with repetitive motion. He was able to perform 25 degrees of extension with pain at the endpoint but no increased pain, fatigue, weakness, or incoordination with repetitive motion. The left and right lateral bending and left and right rotation were all at 30 degrees. There was no evidence of pain, fatigue, weakness, or incoordination with repetitive motion. An x-ray revealed mild degenerative disk at the L4-5 lumbar spine. The examiner determined there was no evidence of a chronic ongoing condition associated with his military service regarding his lower back condition and that it was not secondary to the right knee. As stated above, the Veteran was afforded another VA examination in May 2013 as the Board found the etiological opinion provided by the August 2011 VA examiner inadequate. Here, the Veteran was diagnosed with lumbar spondylosis and degenerative disc disease. He reported pain in his lower back with pain traveling down to his legs and mid-calf. There was also some tingling in certain areas of the legs. No flare ups were reported. The range of motion were 70 degrees of flexion with pain on motion at 60 degrees, 20 degrees of extension without objective evidence of painful motion, and 20 degrees of right and left lateral flexion and right and left lateral rotation without objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions. There was no additional limitation in range of motion following repetitive-use testing or functional loss/impairment of the thoracolumbar spine. The Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. He had constant use of a cane to assist with locomotion. An x-ray revealed advanced spondylosis at the L4-S1 with narrowing of the disc space, sclerosis of the vertebral endplates, and small anterior and posterior osteophytes. There was no evidence of subluxation. There was incidental very mild sclerosis in the inferior left sacroiliac joint, nonspecific. The examiner noted this may represent early degenerative changes. Upon review of the evidence of record, the Veteran's lay statements, and a physical examination, the VA examiner concluded the low back disorder was less likely than not incurred or caused by an in-service injury, event, or illness. The examiner noted that although there were some episodes of low back pain in service, no major problems were found. The Veteran also had no complaints of his back at separation and chronologically he had no complaints of pain for decades. Regarding the Veteran's claim that his low back pain was secondary to his patellofemoral arthritis of the right knee, the examiner stated the medical literature does not support this link. There was no evidence of instability in the knees to cause any condition affecting the Veteran's gait. There was also no evidence of any aggravation beyond the natural progression caused by the knees. After reviewing all the evidence, the Board is unable to grant the Veteran's claim for service connection for a low back disorder on a direct basis or as secondary to the service-connected patellofemoral arthritis of the right knee. While it is appears that the Veteran currently has a low back disorder, the medical evidence of record as a whole supports the proposition that there is no etiological relationship between the origin and/or severity of any low back disorder and service or his service-connected disabilities. Specifically, the May 2013 VA examination provided a negative nexus opinion as to the question of etiology. Therefore, direct service connection is not warranted because while the evidence does show that the Veteran was treated during service, there is no objective evidence of a medical nexus between the Veteran's current low back disorder and his period of military service. While the Board acknowledges the Veteran current diagnosis of lumbar spondylosis and degenerative disc disease, and the Veteran's claim that it is secondary to his service-connected patellofemoral arthritis of the right knee, the lack of evidence indicating the etiology does not warrant a grant of service connection despite the Veteran's claims. The Court has held that where the determinative issue involves causation or a medical diagnosis, competent medical evidence to the effect that the claim is possible or plausible is required. See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The Board acknowledges the Veteran's belief that his low back disorder is secondary to his service connected thoracolumbar strain. However, while the Veteran is competent to report his symptomatology, given the nature of the claim at issue, he does not have the expertise needed to render a diagnosis or offer an opinion as to whether his claimed symptoms are attributable to a particular diagnosed disability. Accordingly, his opinions are not probative and are outweighed by the medical evidence of record. Although the Board is sympathetic to the Veteran's claim, based on the lack of objective medical evidence demonstrating the Veteran's low back disorder is related to service and considering the probative negative nexus opinion, the evidence for the Veteran's claim for direct service connection and secondary to his service-connected patellofemoral arthritis of the right knee is outweighed by the countervailing evidence. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable and the appeal must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). ORDER Entitlement to service connection for bilateral hip disorder, to include as secondary to service-connected patellofemoral arthritis of the right knee, is denied. Entitlement to service connection for a low back disorder, to include as secondary to service-connected patellofemoral arthritis of the right knee, is denied. ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs