Citation Nr: 1325192 Decision Date: 08/08/13 Archive Date: 08/13/13 DOCKET NO. 08-13 120A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected Type II diabetes mellitus (hereinafter "DM"). 2. Entitlement to service connection for the residuals of left knee injuries. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Nigam, Counsel INTRODUCTION The Veteran served on active duty from April 1968 to July 1973, and thereafter, in the National Guard with various periods of active duty for training (hereinafter "ACDUTRA") and inactive duty for training (hereinafter "INACDUTRA") through 1995. This matter initially came before the Board of Veterans' Appeals (hereinafter "Board") on appeal from a June 2007 rating decision of the Department of Veterans Affairs (hereinafter "VA") Regional Officer (hereinafter "RO") in St. Petersburg, Florida. In October 2009, the Veteran testified at a hearing before the undersigned Veterans Law Judge (hereinafter "VLJ") at the RO. A transcript of this hearing is associated with the record. In March 2010 and February 2012, the Board remanded this matter to the RO via the Appeals Management Center (hereinafter "AMC") in Washington DC, for further development, to include obtaining missing service treatment records and obtaining supplemental VA medical opinions. Discussed below, the Board finds that there has been substantial compliance with the February 2012 remand instructions. Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the U.S. Court of Appeals for Veterans Claims (hereinafter "Court") or the Board confers on the Veteran or other claimant, as a matter of law, the right to compliance with the remand orders); see Dyment v. West, 13 Vet. App. 141 (1999) (holding that remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with remand directives). In evaluating this case, the Board has not only reviewed the physical claims file, but has also reviewed the eFolder on Virtual VA (hereinafter "Virtual VA") to ensure a complete assessment of the evidence. Additional, pertinent medical evidence was added to Virtual VA in June 2012, which was considered most recently by the AMC in the October 2012 supplemental statement of the case (hereinafter "SSOC"). As such, the Board will proceed to consider the appeal on the merits. See 38 C.F.R. § 20.1304(c) (2012). FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the matters on appeal have been accomplished. 2. The weight of the competent evidence establishes that it is less likely as not that the Veteran's hypertension was incurred during service or was caused or aggravated by a service-connected disability, particularly DM. 3. The weight of the competent evidence establishes that it is less likely as not that the Veteran's residuals of left knee injuries were incurred during service. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 101, 1110, 1111, 1131, 1153, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for the residuals of left knee injuries have not been met. 38 U.S.C.A. §§ 101, 1110, 1111, 1131, 1153, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A Veteran bears the "'evidentiary burden' to establish all elements of a claim, including the nexus requirement." Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). The Board's duty is to first determine the probative value of all pertinent medical and lay evidence of record based on its credibility and competency, and then weigh the probative value of the evidence regarding all material elements of a claim. See 38 U.S.C.A. § 7104(d); Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). A "veteran is given the 'benefit of the doubt' 'regarding any issue material' to the veteran's claim 'when there is an approximate balance of positive and negative evidence.'" Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § 5107(b)). Thus, if there is conflicting medical evidence, the Board may not ignore or disregard any medical professional's opinion, but may assign greater probative to one medical opinion over by providing an adequate statement of reasons or bases for doing so. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Willis v. Derwinski, 1 Vet. App. 66, 70 (1991). A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In making all determinations, the Board must also fully weigh the probative value of the lay evidence of record against the remaining evidence of record. See King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). If credible, competent lay evidence means 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). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana, 24 Vet. App. at 438; Layno, 6 Vet. App. at 470 (a veteran is competent to report on that of which he or she has personal knowledge). Moreover, lay evidence must not be categorically dismissed as incompetent evidence of medical causation merely because it is lay evidence. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Rather, lay evidence may be competent and sufficient evidence of a diagnosis or nexus if (1) the particular condition at issue is the type of condition that is within the competence of a layperson, (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. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana, 24 Vet. App. at 433, n.4. The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person. See Jandreau, 492 F.3d 1367-77; see also Kahana, 24 Vet. App. at 438, J. Lance dissenting; Robinson v. Shinseki, 312 Fed. Appx. 336, 339 (Fed. Cir. 2009) (nonprecedential). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Duties to Assist and Notify The Veterans Claims Assistance Act of 2000 (hereinafter "VCAA") describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: (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, 486 (2006). The notice must be provided to the Veteran prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA has satisfied its duty to notify by issuing pre- and post-adjudication notice letters in December 2006, April 2010, May 2010, July 2010, July 2011, September 2011, March 2012, April 2012 and June 2012. These letters advised the Veteran of what evidence was required to substantiate his claims for service connection, and of his and VA's respective duties for obtaining evidence. The December 2006 letter also provided notice regarding the disability evaluation and effective date elements of a service connection claim. Dingess, 19 Vet. App. at 473. The claims were most recently readjudicated in an October 2012 SSOC. Accordingly, prejudicial error in the timing or content of VCAA notice has not been established and any error is not outcome determinative. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency). Further, if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome by the following: (1) based on the communications sent to the Veteran over the course of this appeal, he clearly has actual knowledge of the evidence he is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to him by VA, it is reasonable to expect that he understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). The duty to assist provisions of the VCAA have been met. The claims file contains the Veteran's lay statements and hearing testimony, in-service and post-service medical treatment records, Social Security Administration (hereinafter "SSA") records and report of VA examinations (also known in the record as a Disability Benefits Questionnaire or " DBQ "). As noted, the Board remanded the claim in March 2010 for development of the record, to include obtaining outstanding service treatment records from the Veteran's National Guard service, including those dated from 1968 to 1973. In February 2012, the Board again remanded the claim for compliance with the March 2010 remand order under Stegall. In response to a March 2012 request, the National Personnel Records Center (hereinafter "NPRC") indicated that there were no service treatment records located there, and that the records had been retired to another facility. In April 2012, the Florida National Guard was contacted, the attempt of which the Veteran was informed in an April 2012 letter from the AMC. Further attempts were made to obtain the National Guard records to no avail, and in August 2012, the Veteran was telephonically contacted to inform him that a negative response had been received for his service treatment records, from both the NPRC and the RO. He was also notified that some records had been received from the Florida Adjutant General for the dates July 1973 to the present, but that no records dated from April 1968 to June 1973 had been obtained. At that time the RO also issued a "Formal Finding on the Unavailability of Retrieve STR's," and concluded its search. When service treatment records are lost or missing, the Court has held that VA has a heightened duty "to consider the applicability of the benefit of the doubt rule, to assist the claimant in developing the claim, and to explain its decision when the Veteran's medical records have been destroyed." Cromer v. Nicholson, 19 Vet.App. 215, 217-18 (2005) citing Russo v. Brown, 9 Vet. App. 46, 51 (1996). See also Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). All methods appear to have been exhausted in attempting to obtain the missing service treatment records, which are unavailable for consideration. The Board finds no basis for further pursuit of these records, as such efforts would be futile. 38 C.F.R. § 3.159(c)(2), (3). In light of the efforts discussed above, VA has met its heightened obligation to satisfy the duty to assist. See Daye v. Nicholson, 20 Vet. App. 512, 515 (2006); Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). Also, as discussed in detail below, the Veteran has provided inconsistent and irregular accounts of treatment for both of his claimed disabilities, and with respect to his hypertension claim, he has variously reported that its onset occurred many years after service and is caused or aggravated by his service-connected DM. Also, in April 2010, the Veteran completed a VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs, for the "Williams Knee Clinic." The Board notes that limited records from that facility were already of record at the time of this request. In May 2010, the RO requested records from this facility. However, in a VA Form 21-4138, Statement in Support of Claim, dated in August 2010, the Veteran informed the RO that the Williams Knee Clinic no longer exists, and that any further attempts to obtain records from the facility would be futile. He also called the RO in August 2010 to verify that evidence requested from Williams Knee Clinic would not be sent in because the facility no longer existed and the records were destroyed over 20 years ago. The Veteran requested that his claim move forward without further attempt to obtain these records. Thus, the Board finds that further attempt to obtain any records from this facility is unnecessary. At the October 2009 hearing, the undersigned VLJ and representative for the Veteran outlined the issues on appeal and engaged in a colloquy as to substantiation of the claims. Overall, the hearing was legally sufficient and the duty to assist has been met. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Veteran has not made the RO, the AMC, or the Board aware of any additional evidence that must be obtained in order to fairly decide the claims on appeal. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of the issues has been obtained and the case is ready for appellate review. The Board additionally finds that general due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). The Merits of the Claim-Service Connection Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). "Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability. In the absence of a proof of present disability there can be no claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement of a "current disability" is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal; service connection may be awarded even though the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Certain chronic diseases, such as hypertension and arthritis, which are listed in 38 C.F.R. § 3.309(a) may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Id. If a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Id. Even if the disease is not diagnosed during the presumptive period, a veteran can still receive presumptive service connection by showing, through acceptable medical or lay evidence, characteristic manifestations of the disease to the required degree during the presumptive period, followed without unreasonable time lapse by definite diagnosis. Symptomatology shown in the prescribed period may have no particular significance when first observed, but, in light of subsequent developments, it may gain considerable significance. Cases in which a chronic condition is shown to exist within a short time following the applicable presumptive period, but without evidence of manifestations within the period, should be developed to determine whether there was symptomatology which in retrospect may be identified and evaluated as manifestation of the chronic disease to the required degree. 38 C.F.R. § 3.307(c). For VA purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm, or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm, or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1), under Diseases of the Arteries and Veins. These must be confirmed by readings taken two or more times on at least three different days. Id. The Board notes that the Veteran does not contend, nor does the record show, that he was clinically diagnosed with hypertension or with arthritis, as defined under 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1) and 38 C.F.R. § 4.71a, Diagnostic Codes 5002, 5003 and 5010, within one year of his separation from service. Thus, the statutory presumption under 38 C.F.R. §§ 3.307, 3.309 does not apply in this case. If chronicity in service is not established or where the diagnosis of chronicity may be legitimately questioned, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). A claimant "can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in § 3.309(a)." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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). Service connection is warranted for an injury or disease which is incurred or aggravated during a period of ACDUTRA. 38 U.S.C.A. § 101(24)(B) (West 2002); 38 C.F.R. § 3.6(a) (2012). ACDUTRA is, among other things, full-time duty in the Armed Forces performed by Reserves for training purposes or by members of the National Guard of any state. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c)(1). INACDUTRA is part-time duty in the Armed Forces performed by Reserves for training purposes or by members of the National Guard of any state. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c)(1). Active duty also includes authorized travel to or from such duty or service. 38 C.F.R. § 3.6(e). ACDUTRA is not defined as "active" service unless the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty while performing ACDUTRA. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). Service connection for only injury incurred or aggravated during a period of INACDUTRA is warranted (injuries include acute myocardial infarction, cardiac arrest, or cerebrovascular accident). 38 U.S.C.A. § 101(24)(C); 38 C.F.R. § 3.6(a) (2012). INACDUTRA is not defined as "active" service unless the individual concerned was disabled or died from injury incurred or aggravated in the line of duty while performing INACDUTRA. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). VA's General Counsel has held that it was the intention of Congress when it defined active service in 38 U.S.C.A. § 101(24) to exclude a period of INACDUTRA during which a member was disabled or died due to nontraumatic incurrence or aggravation of a disease process. See VAOPGCPREC 86-90. For the most part, in order to qualify for VA benefits, a claimant must be a veteran. See Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006) (status as a "veteran" is one of the five elements of a claim for service-connection benefits). In order to establish his or her entitlement to VA disability compensation benefits, he or she must first establish "veteran" status. There are three ways to establish "veteran status": 1) serve on active duty; 2) serve on a period of ACDUTRA and incur or aggravate an injury or disease during that period of ACDUTRA; or 3) serve on a period of INACDUTRA and incur or aggravate an injury during that period of INACDUTRA. Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). In other words, when a claim for service connection is based only on a period of ACDUTRA or INACDUTRA, there must be evidence that the appellant became disabled as a result of a disease or injury incurred or aggravated in the line of duty during the period of ACDUTRA or INACDUTRA. See 38 U.S.C. §§ 101(2), (22), (24); 38 C.F.R. § 3.6(a); Donnellan v. Shinseki, 24 Vet. App. 167, 172 (2010); Acciola v. Peake, 22 Vet. App. 320, 324 (2008) (citing Mercado-Marchtinez v. West, 11 Vet. App. 415, 419 (1998); Paulson v. Brown, 7 Vet. App. 466, 470 (1995)). In the absence of such evidence, the period of ACDUTRA or INACDUTRA would not qualify as "active military, naval, or air service," and the appellant would not qualify as a "veteran" by virtue of the ACDUTRA or INACDUTRA service alone. 38 U.S.C. § 101(2), (24); see Acciola, 22 Vet. App. at 324. Certain evidentiary presumptions, such as the presumption of sound condition at entrance to service, the presumption of aggravation during service of preexisting diseases or injuries which undergo an increase in severity during service, and the presumption of service incurrence for certain diseases which manifest themselves to a degree of disability of 10 percent or more within a specified time after separation from service are provided by law to assist veterans in establishing service connection for a disability or disabilities. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.304(b), 3.306, 3.307, 3.309 (2012). Generally, no presumptions (including the presumptions of soundness, aggravation, or for presumptive diseases) attach to periods of ACDUTRA and INACDUTRA unless "Veteran" status is attained during those periods. Paulson v. Brown, 7 Vet. App. 466, 470 (1995). These evidentiary presumptions do not extend to those who claim service connection based on a period of ACDUTRA. Smith v. Shinseki, 24 Vet. App. 40 (2010) (presumption of soundness and presumption of aggravation not applicable to ACDUTRA); Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (Board did not err in not applying presumptions of sound condition and aggravation to claim where appellant served only on ACDUTRA and had not established any service-connected disabilities from that period). Also, some presumptions will not apply to certain periods of ACDUTRA and INACDUTRA. See Smith v. Shinseki, 24 Vet. App. 40, 45-46 (2010). If the claimant did not serve for any period of time on active duty, he or she must establish service connection for a disability on a direct basis first in order to achieve "veteran" status and be entitled to compensation. Paulson v. Brown, 7 Vet. App. 466, 470 (1995). Thus the key initial question in this case is whether the Appellant qualifies as a "veteran" for VA purposes and, thus, whether he is entitled to the presumptions of sound condition and aggravation. A disability can be service connected on a secondary basis if it is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(a). Secondary service connection may be established by any increase in severity (i.e., aggravation) of a nonservice-connected condition that is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(b), effective October 10, 2006. See 71 Fed. Reg. 52,744-52,747 (September 7, 2006). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); Tobin v. Derwinski, 2 Vet. App. 34, 39 (1991). Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. A claim for secondary service connection requires competent medical evidence linking the asserted secondary disorder to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998). See also Wallin v. West, 11 Vet. App. 509, 512 (1998) and McQueen v. West, 13 Vet. App. 237 (1999) (both indicating, like Velez, that competent medical nexus evidence is required to associate a disorder with a service-connected disability). In short, in order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Hypertension The Veteran contends that his hypertension is secondary to his service-connected DM. He also asserts that he was treated for high blood pressure while serving on active duty in the military. During his hearing in October 2009, the Veteran testified that he had been treated with hypertension medication for "about five or six years...Or longer." He reported that when he was in Vietnam he was taking medication for high blood pressure, but could not recall which medication he had been prescribed. He indicated that he had also been treated for hypertension while serving in the National Guard, and had a number of flare-ups, for which he had been monitored and prescribed medication. He testified that he discontinued taking the medication sometime after leaving Vietnam, but resumed taking it "about eight years or six years ago." On his VA Form 21-526, Veteran's Application for Compensation and/or Pension, received in November 2006, the Veteran indicated that he first experienced hypertension in June 1996. As hypertension is considered a chronic disease under 38 C.F.R. § 3.309(a), service connection can be granted for this disease by establishing continuity of symptomatology since service under 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board observes that the Veteran has attested to his long-term treatment for high blood pressure and medication-controlled hypertension, which, as a lay person, he is competent to report. Jandreau v. Nicholson, 492 F.3d 1372 (2007) (lay evidence can be competent to establish diagnosis of a condition when a layperson is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms supports a later diagnosis by a medical professional). However, the Board finds that the question of when the Veteran was first diagnosed with hypertension, or if his current hypertension is related to his service-connected DM are complex medical questions outside the competence of a layperson. He has not been shown to have the diagnostic capabilities to determine that he experienced hypertension in service or thereafter. Moreover, he has not described any observable symptoms of hypertension that would support his contention that he experienced it since service. Further, although the Veteran has argued that he was pre-diabetic when he was first diagnosed with hypertension, it is clear that his opinion that his DM has caused or contributed to his hypertension is invalidated by own his contention that he was treated for hypertension while serving in Vietnam, which was decades before he was diagnosed with diabetes. His own opinion is therefore not competent evidence of a diagnosis or etiology. See Kahana, 24 Vet. App. at 433, n.4; Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Turning to the clinical evidence of record, throughout the Veteran's period of active service, and ACDUTRA and INACDUTRA, his blood pressure readings ranged from 104/68 to 148/68, with the majority of readings averaging below 148/68. A June 1986 "Statement of Medical Examination and Duty Status indicates complaints of a sudden onset of sharp pressure, left sided chest pain, 9 days prior to admission. The Veteran presented to the emergency room and was admitted for musculoskeletal chest pain. An admission narrative summary from the Naval Hospital in Jacksonville, Florida, indicates he had no cardiac history, but admitted to smoking 1 pack per day for 20 years. The review of symptoms was unremarkable, the blood pressure reading was 130/80, and the chest was described as symmetric without adenopathy. The Veteran was diagnosed with musculoskeletal chest pain, and after achieving a maximal heart rate with no evidence of abnormality on a Bruce protocol stress test, he was discharged to duty. In March 1987, the Veteran submitted a statement that he was treated with high blood pressure medication at the time that the accident occurred, but that he left his medication at home, "got over heated and collapsed." He indicated that he was then admitted to the hospital and had his heart monitored over night, but that the results were "ok." However, on a "Medical History Questionnaire to Evaluate Medical Status of Dental Patients," also dated in March 1987, the Veteran specifically indicated that he did not ever have heart trouble or abnormal blood pressure. In July 1987, the Veteran was noted to have a history of hospitalization in June 1986 for atypical chest pain, and in April 1987 for peptic ulcer disease and abdominal pain. He was diagnosed with atypical chest pain, no evidence of coronary artery disease, and with resolving peptic ulcer disease. His blood pressure reading was 142/72 at that time. An August 1987 emergency room report from the Naval Hospital in Jacksonville, Florida shows the Veteran complained of epigastric pain for 2 days. It was noted that the Veteran was being followed by a civilian doctor who put him on some medications. He complained of having to work in the heat, and noted that he was not supposed to be in the heat due to his high blood pressure. An accompanying "Emergency Care and Treatment Medical Record" shows the Veteran was taking Tagamet and possibly high blood pressure medication. However, on a "Dental Patient Medical History" report, dated in September 1987, the Veteran specifically denied ever having been treated for high blood pressure or a heart condition. On a March 1988 "Health Risk Appraisal Assessment," the Veteran denied that he was informed in the last 5 years that he had high or borderline high blood pressure, and denied current treatment for high blood pressure. Also, on a "Dental Patient Medical History," dated in April 1988, he indicated that he never had been treated for a heart condition and never had any shortness of breath, or palpitation of the heart. He did not provide information as to whether or not he had been treated for high blood pressure. In April 1989, he underwent a cardiovascular screening, wherein it was determined that he was cleared for the Army's Physical Fitness Training and Testing Program. In July 1992, the Veteran underwent a second cardiovascular screening, wherein it was determined that he was cleared for the Army's Physical Fitness Test. In October 1998 and October 2001, the Veteran underwent cardiac stress testing with nuclear gated SPECT analysis, after complaining of chest pain symptoms and having an abnormal resting electrocardiogram (hereinafter "EKG" or "ECG"), with normal results. In April 2004 the Veteran was observed to have elevated blood pressure on private physical examination. A private stress test report, dated in May 2004, shows that hypertension was indicated prior to, during the exercise and during recovery. The passage of so many years between his service separation and his first documented diagnosis of hypertension is evidence against the claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board finds this date of onset of the Appellant's current symptomatology, long after service, to be highly credible as it was generated with a view towards ascertaining the Appellant's then-state of physical fitness and is akin to a statement of diagnosis or treatment. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision); see also LILLY'S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rationale that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). In March 2007, the Veteran underwent a VA DM examination. Here, he reported that he was told that his blood pressure was high in 2001. He also reported that he had been diagnosed with DM approximately six years prior to the examination. The examiner noted that the Veteran had mild hypertension, which was controlled with a single dose of hydrochlorothiazide daily. The examiner also noted a history of hypertension since 1987. The Veteran denied having any heart condition, and there was no data to support a stroke or coronary heart disease noted. The examiner provided a cursory but unequivocal opinion that the Veteran's essential hypertension without proteinuria was not related to the DM. The Board accords this opinion little probative value as it is inadequate in multiple ways. First, the Board finds that the opinion does not adequately address the two separate questions comprising a secondary service connection theory of entitlement: causation and aggravation. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995). Second, the opinion failed to address any relationship between the Veteran's hypertension and his military service. Third, the opinion is cursory and conclusory. The probative value of medical opinion evidence, among other factors, is based on whether a clinician was "informed of the relevant facts" and medical history in rendering a medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this regard, the examiner failed to explain why the Veteran's hypertension is not related to his DM. Without such reasoning, the Board is unable to assign more than minimal probative weight to the examiner's conclusions; thus, it is insufficient to decide the matter. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). In July 2007, "Dr. Price," the Medical Director of the "University of Florida Yulee Family Practice Center," provided a medical opinion that the Veteran's hypertension was as likely as not caused by his DM "because of the Micro-Vascular Disease." However, the Board finds this opinion to be inadequate for VA rating purposes as it did not identify what was meant by the "Micro-Vascular Disease," or the significance of such a disease in the Veteran's diagnosis, nor did it provide more than a cursory opinion, lacking in any explanation or rationale as to why the Veteran's hypertension was caused by his DM. Moreover, Dr. Price appears to have ignored the fact that the Veteran has reported having high blood pressure and hypertension since his active service, which was decades before he was diagnosed with DM. The probative value of medical opinion evidence, among other factors, is based on whether a clinician was "informed of the relevant facts" and medical history in rendering a medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In his VA Form 9, Appeal to Board of Veterans' Appeals, received in May 2008, the Veteran reported that Dr. Price had advised him that he was a borderline diabetic, and delayed diagnosing him as a diabetic in the hope that he would be able to control his diabetes through diet and exercise. He argued that in the interim of when he was told that he was borderline diabetic and when he was diagnosed as a diabetic, he became hypertensive. A VA hypertension examination report, dated in October 2011, reveals the Veteran was first diagnosed with hypertension in 2001; however, the Veteran provided a medical history that he was started on medication for high blood pressure while serving on active duty in Vietnam, and has continued to require blood pressure medications since that time. It was noted that the Veteran did not have a history of a diastolic blood pressure elevation to predominantly 100 or more. On physical examination, the Veteran's blood pressure readings were noted as 162/82, 136/83 and 141/81. No further pertinent physical findings, complications, conditions, signs or symptoms related to hypertension were observed. The examiner opined that it would be only with resort to mere speculation to opine whether or not the Veteran's current hypertension was caused or aggravated to any degree by his military service, and that it would be only with resort to mere speculation to opine whether or not the Veteran's current hypertension was caused or aggravated to any degree by his DM. The examiner explained that review of the record, including the opinion of "Dr. Price" in July 2007, shows that hypertension was not documented during the Veteran's active duty military service or National Guard ACDUTRA. The examiner noted that service treatment records covering the period of the Veteran's active duty service while deployed in Vietnam (1969 to 1970) could not be located to confirm his reported treatment of hypertension, and that on subsequent National Guard examinations in January 1980 and April 1992, the Veteran specifically indicated that he did not have any blood pressure problems, had normal blood pressure readings, and had no reported antihypertensive medications. The examiner noted that there was no objective evidence for any hypertension occurring during the Veteran's active military service or National Guard ACDUTRA, and concluded that there was no objective evidence that the Veteran's hypertension was caused or aggravated to any degree by his military service or National Guard ACDUTRA. Moreover, the examiner observed that the objective evidence indicates the Veteran's onset of hypertension was at or before his documented onset and treatment of DM in 2001. The examiner indicated that it was not possible to determine from the available objective evidence the precise degree of contribution, if any, that the Veteran's DM made to his hypertension. However, the examiner concluded that there was no objective evidence that the Veteran's DM caused or aggravated to any degree his current hypertension. In Jones v. Shinseki, 23 Vet. App. 382 (2009), the Court held that a determination that a diagnosis or etiology opinion is not possible without resort to speculation is a medical conclusion just as much as a firm diagnosis or a conclusive opinion. However, a bald statement that it would be speculative for the examiner to render an opinion as to etiology or diagnosis is fraught with ambiguity. For example, it is not clear whether the examiner lacks the expertise to render such an opinion, or whether some additional testing or information is needed, and possibly available, that would permit such an opinion, either of which would render the opinion inadequate for resolving the claim. Thus, before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence. Cf. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Court in Jones further held that the examiner may also have an obligation to conduct research in the medical literature depending on the evidence in the record at the time of the examination. See Wallin v. West, 11 Vet. App. 509, 514 (1998). The phrase "without resort to speculation" should reflect the limitations of knowledge in the medical community at large and not those of a particular examiner. Id. The Board notes that the October 2011 VA examiner couched the portion of his opinion addressing the likelihood that the Veteran's DM caused or aggravated his hypertension in speculative terms. Therefore, the Board finds that the probative value of the October 2011 examiner's opinion is limited to the opinion regarding the likelihood that the Veteran's hypertension was related to his military service. In this regard, the Board finds the examiner's opinion highly probative as the opinion is well-reasoned and based on review of the pertinent records and relevant medical history, and constitutes objective evidence that the Veteran's hypertension is not related to his service. See Stefl v. Nicholson, 21 Vet.App. 120, 124 (2007); Caluza, 7 Vet.App. at 511-512. More recently, on VA DM examination in May 2012, the examiner opined that it was less likely as not that the Veteran's DM permanently aggravated his hypertension. The examiner explained that the Veteran's hypertension had its onset many years prior to his DM, and that there was no objective data to support a finding of aggravation of the hypertension. Although the May 2012 VA examiners' opinion does not expressly discuss the Veteran's own report of having continuous symptoms during and after service, these omissions are nonconsequential for several reasons. First, as a general matter, a medical examiner is not required to comment on every favorable piece of evidence in a claims file. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012). Furthermore, for the reasons discussed above, the lay statements asserting a continuity of symptoms are found not competent to relate the Veteran's current hypertension to his service, nor, as discussed, are they found to be credible. Also significant, an overall reading all of the VA examiners' opinions of record is that it is very unlikely that any current hypertension is related to his military service, and that there was no diagnosis of hypertension or high blood pressure in service or shortly thereafter. Any deficiency in the VA examiner's factual foundation or explanation is consequently immaterial. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (a VA examination report "must be read as a whole" to determine an examiner's rationale); Acevedo v. Shinseki, 25 Vet.App. 286, 293-942012); see also Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Accordingly, the probative value of the VA examiners' opinions is not materially diminished in this respect. See Nieves-Rodriguez, 22 Vet. App. at 304. Such a medical opinion, which is factually accurate, fully articulated, and based on sound reasoning, carries significant weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board, in its own lay capacity (as with the Veteran), is not otherwise qualified to call into question the VA examiner's medical judgment, nor does the Board find any reason to do so. See, e.g., Monzingo, 26 Vet. App. 97, 106 (2012). In conclusion, the Board finds after careful review of the entire record that the weight of the evidence is against the Veteran's claim of service connection for hypertension on either a direct or secondary basis. In reaching this conclusion the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Residuals of left knee injuries In his VA Form 21-526, Veteran's Application for Compensation or Pension (hereinafter "Form 526"), received in April 2005, the Veteran reported that he sustained bilateral knee damage in service, with a date of onset in August 1993. In a subsequent VA Form 21-526, received in November 2006, the Veteran reported that he experienced a left knee injury in 1969, for which he was treated by Army doctors until 1995, by the "Williams Knee Clinic, by "Dr. Paul Shirley," and by "Dr David Heekin." A December 1992 note from the "Williams Knee Clinic, P.A." shows that the Veteran had been treated for a knee injury. A March 1993 statement from "Dr. Edward Tribuzio," a family practitioner, reflects that the Veteran had been diagnosed with left knee pain secondary to a medial meniscus tear. A September 1993 radiological report from "Nassau General Hospital" reveals an impression of osteoarthritis and chondromalacia of the patella. In March 2001, the Veteran underwent a private left knee X-ray after complaining of left knee pain, which revealed findings of joint space narrowing with extreme sclerosis and spurring on the joint margins. The Veteran was diagnosed with an impression of advanced degenerative arthritis and chondromalacia of the patella. In June 2003 and February 2005, additional sets of private left knee X-ray studies were taken, which revealed impressions of severe degenerative changes and severe osteoarthritis of the left knee. In July 2003, Dr. Shirley injected and aspirated the left knee. In March 2005, the Veteran underwent a left knee arthroscopy, also performed by Dr. Shirley. In April 2005, Dr. Shirley observed that the left knee had "Grade IV down to bone, chondral damage, meniscal tears, etc." In December 2005, the Veteran was diagnosed by Dr. Heekin with left knee degenerative joint disease, end-stage, activity limiting, and was tentatively scheduled for a left total knee replacement in March 2006. In March 2006, the Veteran underwent a left total knee replacement at "St. Vincent's Hospital." In March 2007 the Veteran underwent a VA joints examination, wherein he complained of left knee pain since 1970. Specifically, he reported that he fell off of the back of a truck while stationed in Vietnam, which caused him to tear ligaments in his left knee. He noted that he was evacuated to the 67th Evacuation Hospital in Vietnam and was on quarters for one month, but returned to active duty thereafter. The examiner noted a history of the Veteran undergoing arthroscopic surgeries on the left knee in 1980 and 2005, at St. Vincent's Hospital, and undergoing a total left knee replacement in April 2005 at St. Vincent's Hospital. The Veteran reported that he was retired in 2005, but that his last job was as a machinist, which he worked at for 30 years. The Veteran was diagnosed with residuals status-post total left knee replacement. No opinion as to the etiology of the left knee disability was provided at that time. In July 2007, the Veteran's cousin and sister submitted statements in which they reported their observations that the Veteran had a noticeable limp in his left knee after returning from his tour in Vietnam, which he told them he sustained from an injury in Vietnam. In September 2009, both of his sisters submitted additional statements and reported that while the Veteran was serving in Vietnam their mother passed away in July 1970, and that when he returned home for her funeral, he was on crutches. During his hearing in October 2009, the Veteran reported that he injured his left knee in service on two occasions. First, he testified that he "[couldn't] remember the activity in the motor pool, but [he] fell and tore all of the ligaments of the knee then." Second, he testified that while serving in Vietnam he jumped off the back of a truck and "fractured [his] knee and tore everything up in [his] knee." He noted that four days after sustaining this injury he left Vietnam on emergency leave because his mother died, and he was given crutches, which he used at his mother's funeral. He clarified that he could not remember how his first injury in the motor pool, only that it occurred near a jeep and that he felt he had twisted something in the knee. He indicated that he had limped for 2 or 3 days after that injury, but did not have pain or require crutches. However, he noted that when he injured the left knee the second time, he was put on two profiles for his knees while serving in the National Guard. He also reported that he was issued a brace and told to stay on his crutches for 3 to 4 weeks, after which he returned to Vietnam. He indicated that he was no longer on crutches after his return, and was feeling better, although he still had some problems. The Veteran also testified that in the 1980's he underwent 2 arthroscopic surgeries, and in 2005 he underwent a total knee replacement. On VA knee and lower leg examination, dated in October 2011, the Veteran was diagnosed with left knee residuals status-post total knee replacement, with a date of onset of 1992. He provided a history of injuring the left knee in Vietnam in July 1971 when he was thrown off of an Army truck by Vietnamese people who were attempting to steal food. The Veteran reported that he was required to use crutches to attend his mother's funeral soon after, and that in 2005 he was required to undergo a left total knee replacement, which has left him in chronic pain. Prior to the left total knee replacement, the Veteran had undergone a meniscus repair in 2003. The examiner opined that it would be only with resort to mere speculation to opine whether or not the Veteran's current left knee disability was caused or aggravated to any degree by his military service. The examiner also opined that it was less likely as not that the Veteran's current left knee disability was caused or aggravated to any degree by his DM. The examiner observed that the available service treatment record did not document any injury for the left knee or left leg during the Veteran's active duty military service or National Guard ACDUTRA. The examiner noted that the service treatment records covering the period of the Veteran's deployment to Vietnam (1969 to 1970) could not be located to confirm the reported left knee injury occurred during his Vietnam service. The examiner noted that on subsequent National Guard examination reports, dated in January 1980 and April 1992, the Veteran denied having any knee problems and had a normal musculoskeletal examination. The examiner noted that there was no objective evidence of any left knee injury occurring during the Veteran's active duty military service or National Guard ACDUTRA, and therefore there was no objective evidence that the Veteran's current left knee disability was caused or aggravated by his active duty military service or National Guard ACDUTRA. The examiner explained that the current medical literature did not support a cause and effect relationship between DM and the development of degenerative joint disease of the knee, and opined there was no objective evidence that the Veteran's current DM caused or aggravated to any degree his current left knee disability. As noted, the Court in Jones v. Shinseki, 23 Vet. App. 382 (2009) held that a determination that a bald statement that it would be speculative for the examiner to render an opinion as to etiology or diagnosis is fraught with ambiguity. Thus, before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence. Cf. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In August 2012, a VA medical opinion was obtained, which provided a diagnosis of degenerative joint disease of the left knee status-post total knee replacement in March 2006. The Veteran gave a history of injuring his left knee on active duty. Specifically, he reported that he first injured his knee in Vietnam after falling off a truck, which caused him to fracture the knee and tear ligaments in the knee. He indicated that at that time he was taken to the hospital where they performed an X-ray study and his knee was wrapped in a cast. He could not recall if the cast was removable, but noted that shortly thereafter he left Vietnam to attend his mother's funeral. He reported that he did not return to Vietnam after the funeral, but was transferred to "Fort Stewart" in Georgia. He reported that he could not remember if he sought further medical attention for his left knee while at Fort Stewart, but that he had removed his own cast. He also reported that he was called to duty in Miami for 3 months after Hurricane Andrew in 1992, and reinjured his left knee. When asked if he sought medical attention for his left knee after his separation from service, the Veteran reported that he underwent two arthroscopic surgeries for the left knee in the 1980's, and that he had seen a doctor for left knee complaints for 4 years prior to the surgeries. The examiner noted that there were no available records to confirm that these surgeries took place. However, the examiner observed that both Reports of Medical History and Examination, dated in January 1980, and an Evaluation for Retainability, dated in July 1987, were silent for a knee disability and the Veteran checked "no" to "trick or locked knee." The examiner also observed that Reports of Medical History and Examination, dated in May 1989, and in April 1992, were silent for any knee condition. The examiner noted that a December 1992 report from the Williams Knee Clinic showed "Due to Wilbert's knee injury he is no longer able to run." The examiner addressed the reports from Dr. Tribiuzio, Dr. Price, Dr. Shirley and Dr. Heekin as well. The examiner opined that, specifically taking into consideration all relevant documented treatment history, including the March 1993 private treatment record identifying a meniscal tear and the lay testimony, the Veteran's left knee degenerative joint disease status-post total knee replacement in 2006 was less likely as not due to an incident of the Veteran's military service. The examiner observed that the Veteran reported that he was able to resume his duties for the remaining 2 to 3 years of his active duty after giving a history of fracturing his knee. The examiner explained that despite the unavailability of certain service treatment records, and relying upon the Veteran's lay statements and testimony of the events that caused his alleged injuries, it was doubtful that someone with a history of a knee fracture, torn ligaments and cartilages would be able to return to baseline functions, especially rigorous military maneuvers/training exercises/activities, without significant complaints, disability or repeated medical visits for the residuals in a year or two following such an incident. The examiner noted that it was also doubtful that the type of fracture the Veteran reported sustaining would be treated with a cast that the Veteran could remove himself. The examiner observed that after separation from active duty the Veteran was able to return to work as a cook and cut trees for a pulp mill until 1976, while simultaneously going for training in the National Guard. The examiner noted that the service treatment records were effectively silent for knee complaints. The examiner opined that it would be more likely that the reported incident was a contusion with skin laceration which healed, without complaints, and therefore, no further complaints or medical visits afterwards. The Veteran reported that after separation from active duty he first sought medical attention for claimed left knee condition 4 years prior to his first left knee arthroscope in the "1980's," which would be at least 3, likely more years after separation from active duty. The examiner noted that the Veteran's earliest documentation of medical visits indicating left knee problems was on the Dec 1992 report from the Williams Knee Clinic, and that it was nearly 20 years after separation from active duty. The examiner concluded that, although the Veteran appeared to be truthful in his contentions, it was an unfortunate reality that retrograde memory for dates and events might not be as accurate or reliable as actual documented records, and in the Veteran's case, it could not be ruled out that the current left knee disability was the result of strenuous occupation stresses and daily activities, as well as aging. As noted, as arthritis is considered a chronic disease under 38 C.F.R. § 3.309(a), service connection can be granted for this disease by establishing continuity of symptomatology since service under 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran and his family are generally competent to testify in regard to the onset and continuity of his left knee symptomatology and their lay observations thereof. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Also, a lay person may speak to etiology in those limited circumstances where a nexus is obvious merely through observation, such as a fall leading to a broken leg. Jandreau, 492 F.3d 1372, 1376-77. In this case, the question of whether the Veteran's presently diagnosed residuals of left knee injuries are related to his military service is within the competence of a layperson to discuss. In such a case, the Veteran's own opinion would be potentially competent evidence of a nexus. See Kahana, 24 Vet. App. at 433, n.4; Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Yet, even if accepting the Veteran's statements as to the onset of his left knee disability to be competent evidence and even when deeming the Veteran competent to speak to the etiology of his current left knee disability, such evidence is not credible. In this regard, the Board notes that there have been gross inconsistencies in the Veteran's presentation of the events that led to his left knee being injured throughout the course of the appeal. Such inconsistency impacts negatively on the credibility of his current reports. See Buchanan v. Nicholson, 451 F3.d 1331, 1336-37 (Fed. Cir. 2006) (stating that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc.".); see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (stating that "[t]he credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character."). As the claimant in this case, the Veteran has an interest in the outcome of that upon which he has opined. This interest in the outcome impacts negatively on his credibility and further reduces the weight of his opinion. Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("Although interest may affect the credibility of testimony, it does not affect competency to testify."); see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995) ("The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character"). The Board finds that the evidentiary assertions of the Veteran are inherently incredible on the basis of the fact that he often contradicts his own statements made during his in-service treatment, post-service treatment, and on VA examination, in which he has a monetary interest in that contradiction. Instead, the Board relies heavily upon the opinion of the August 2012 VA examiner, which is well-reasoned and based on review of the pertinent records and relevant medical history, and which constitutes highly probative evidence that the Veteran's current left knee residuals are not related to his service. See Stefl v. Nicholson, 21 Vet.App. 120, 124 (2007); Caluza, 7 Vet.App. at 511-512. Further, this opinion is supported by the clinical findings throughout the record, which show an erratic and disjointed history of complaints of left knee problems, and which indicate that following his service, the Veteran was employed in professions that required him to perform many physical tasks and place wear and tear on both of his knees. Importantly, the August 2012 VA examiner took into account the fact that some of the Veteran's service treatment records were unavailable for review, and that based on the lay testimony, and the fact that he was able to resume working and remain in service even after purportedly fracturing his knee and tearing ligaments and cartilage, found that it was unlikely that his injury occurred as he stated. Such a medical opinion, which is factually accurate, fully articulated, and based on sound reasoning, carries significant weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board, in its own lay capacity (as with the Veteran), is not otherwise qualified to call into question the VA examiner's medical judgment, nor does the Board find any reason to do so. See, e.g., Monzingo, 26 Vet. App. 97, 106 (2012). In conclusion, the Board finds after careful review of the entire record that the weight of the evidence is against the Veteran's claim of service connection for the residuals of left knee injuries. In reaching this conclusion the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for hypertension is denied. Service connection for the residuals of left knee injuries is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs