Citation Nr: 1325367 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 04-07 202 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES Entitlement to service connection for a disability of the bilateral lower extremities, including the right knee and both hips, to include as secondary to a service-connected pelvic fracture with right thigh numbness. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. Adamson, Counsel INTRODUCTION The Veteran had active service from August 1971 to August 1974 and from December 1976 to December 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2002 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In November 2007, October 2009, May 2011, June 2012, and May 2013 the Board remanded the appeal for further development, and it once again returns to the Board for appellate review. In May 2007, the Veteran testified before the undersigned during a travel board hearing. A transcript of the proceeding has been associated with the claims file. The record before the Board consists of the Veteran's paper claims files and an electronic file known as Virtual VA. FINDINGS OF FACT The Veteran's disability of the bilateral lower extremities, including degenerative joint disease of the right knee and mild degenerative changes to both hips, did not have its onset in service, did not manifest within one year of separation from service, is not the result of a disease or injury incurred in active service, and has not been causally related to a service-connected disability by competent evidence. CONCLUSION OF LAW A disability of the bilateral lower extremities, including degenerative joint disease of the right knee and mild degenerative changes to both hips, was not incurred in active service, may not be presumed to have been incurred in active service, and was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist VA has a 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 claimant and his representative, if applicable, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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. This notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Further, in Dingess v. Nicholson, the Court held that, upon receipt of an application for a service-connection claim, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his claim. 19 Vet. App. 473 (2006); see also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. The Board finds that the duty to notify was satisfied by letters sent to the Veteran in November 2001 and November 2007. These letter addressed all of the notice elements, although the Board recognizes that complete notice was not sent prior to the initial unfavorable decision by the RO in April 2002. The claim, however, was subsequently readjudicated, most recently in a June 2013 supplemental statement of the case (SSOC). Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). Moreover, any defect in the timing of the notice was harmless error as service connection is being denied on the merits, and no rating or effective date is being assigned. Therefore, the Board finds that VA has fulfilled its duty to notify. VA has also satisfied its duty to assist the Veteran at every stage of this case. The Veteran's service treatment records, as well as all identified post-service VA medical records pertinent to the years after service, several VA examination reports, the Veteran's hearing testimony and his written lay statements are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. VA examinations were obtained in April 2002, June 2009, November 2011, and May 2013. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). While the earlier reports were deemed by the Board to be partially inadequate, the Board remanded the matter several times to ensure a fair evaluation of the Veteran's claim. Following the additional development, the Board finds that the VA opinions obtained in this case are adequate, as they are predicated on a reading of the service and post-service medical records in the Veteran's claims file and take into consideration the Veteran's competent lay statements regarding the onset, frequency and severity of his lower extremity symptoms and their history. These opinions, when considered as a whole, take into account all of the pertinent evidence of record, to include the Veteran's service and post-service records and his lay statements, and provide a complete rationale for the opinions stated, relying on and citing to the records reviewed. There is adequate medical evidence of record to make a determination in this case. The transcript of the Veteran's May 2007 Travel Board hearing as well as other lay statements provided by the Veteran and his representative are also of record and were considered when adjudicating these claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) requires the Veterans Law Judge (VLJ) who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the undersigned VLJ discussed with the Veteran the elements of the claim that were lacking to substantiate the Veteran's claims for benefits. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims files that might have been overlooked or was outstanding that might substantiate the claims. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits. As such, the Board finds that, consistent with Bryant, the undersigned VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. VA has also assisted the Veteran and his representative throughout the course of this appeal by providing them with a SOC (statement of the case) and SSOCs (supplemental statements of the case), which informed them of the laws and regulations relevant to this claim. For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. 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). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent." However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability benefits. Medical evidence of a current disability and nexus is not always required to establish service connection. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). 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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (footnote omitted). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence 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)(2) . Under section 3.310(a) of VA regulations, service connection may also be established on a secondary basis for a disability that is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 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. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Service connection for certain chronic diseases may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year (three years for active tuberculous disease and Hansen's disease; seven years for multiple sclerosis) from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term "chronic disease" refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where a chronic disease under 3.309(a) is "shown as such in service" ("meaning clearly diagnosed beyond legitimate question," Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)), or in the presumptive period so as to permit a finding of service connection, 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). In cases where a chronic disease is "shown as such in service", the Veteran is "relieved of the requirement to show a causal relationship between the condition in service and the condition for which service-connected disability compensation is sought." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Instead, service connection may be granted for subsequent manifestations of the same chronic disease without any evidence of link or connection between the chronic disease shown in service and manifestations of the same disease at a later time. In other words, "there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. If evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not "shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned," i.e., "when the fact of chronicity in service is not adequately supported," then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. § 3.303(b). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. The Veteran has perfected the claim as to whether he is entitled to service connection for disabilities to his lower extremities, his right knee and bilateral hips, in particular. The Veteran contends that he has current disabilities that were caused by or aggravated by his already service connected residuals of a fractured pelvis. In the alternative, the Veteran argues that the current disabilities to his right knee and bilateral hips were caused by parachute jumps during service. The Board does not doubt that the Veteran has a current disabilities of the bilateral hips and right knee. While early in the Veteran's claim, the presence of a current disability was in question, the most recent VA examination report confirms that the claimed disabilities exist. In particular, while April 2002 x-ray results showed normal hips bilaterally, May 2010 x-rays confirmed slight narrowing of the joint superiorly compatible with early degenerative changes. With regard to the right knee, June 2002 magnetic resonance imaging (MRI) revealed medial meniscal tear, effusion and osteochondral defect in the medial condyle, and September 2007 x-ray confirmed mild degenerative changes. Thus, the initial element for establishing service connection for the lower extremity disabilities in question, the existence of a current disability, is clearly met in this case. The question is whether the current disabilities were caused by, aggravated by or are otherwise due to an event of the Veteran's active service, or shown to be caused by or aggravated by the service-connected pelvic fracture. Service treatment records confirm that the Veteran was indeed involved in a motor vehicle accident in October 1973, during which he was thrown from the vehicle and injured his pelvis. January 1974 notes show that the pelvic fracture was then healed. No residual symptoms to the hips or right knee are noted. August 1974 clinical notes show a report of soreness in the right leg, but makes no mention of the knee. The record includes a September 1975 VA examination report, which was completed at the time a compensation claim was being initiated just prior to his separation from service during the first service period. This claim was later withdrawn due to the Veteran's reentry into the service. At that time, the Veteran reported soreness on the lateral left side of the pelvis, which was noted as a condition that comes and goes. He reported that "otherwise lower extremities are negative." Physical examination revealed normal motion in the joints of the lower extremities and that the pelvis was level. Thus, two years following the in-service accident, there was no evidence of hip or right knee disability. In May 1978, the Veteran sought treatment related to constant aching pain over the left iliac crest, which was noted as "resultant from old fractures - auto and parachute accidents." The Veteran received pain medication at that time. A May 1978 notation shows that x-ray of the hip was taken in April 1978 with normal results. Several notes show ongoing prescription of medication for pain. In October 1978 physical examination revealed tenderness laterally and anteriorly over the hip joint with extreme flexion and extreme rotation. The physician noted this as due to an old injury. In April 1979, the Veteran sought treatment again, noting that the pain continues in the left hip and that he experienced weakness in both hips. He was referred for orthopedic treatment, however, no such orthopedic is shown in the record. The last clinical note in service is dated in September 1979, and it shows ongoing pain over the left anterior/pelvic area. The Veteran separated from service several months later. A November 1979 Report of Medical History completed by the Veteran at the time of his separation examination shows that he reported no "trick or locked knee" and there is also no indication of symptoms related to the hips at that time. The accompanying examination report completed by the physician includes a notation of full range of motion in the right and left hip and makes no mention of any abnormality in the right knee. Following service, in February 1980, the Veteran underwent VA examination, at which time he reported ongoing pain on the left side of the pelvis. X-ray at that time showed normal hips, bilaterally. No diagnosis was made as to the hips. Moreover, again, no symptoms were reported as to the right knee. In October 1987, the Veteran again sought treatment related to pain in the left iliac crest. In June 1994, the Veteran continued to report pain in the same area. A September 1996 report notes chronic left hip/pelvic pain. The Veteran underwent VA joints examination in October 1997, at which time no symptoms were reported related to the knee, but ongoing pain was noted in the hips. The VA examiner did document that at the time that the Veteran worked for the postal service and had for a sixteen-year duration. He estimated that he walked four to five miles per day. Physical examination of the lower extremities was normal, although there was noted decreased sensation of the right lateral hip, but it was reported to be not anatomically related to the left pelvic fracture. No diagnosis was rendered as to the hips, which were noted as normal. In April 2001, a VA psychology note shows that the Veteran had applied to be medically retired from the postal service due to his back and hip problems. In June 2001, the Veteran had an x-ray examination of the left hip to rule out degenerative joint disease. X-ray at that time was normal. In March 2002, VA clinical outpatient notes show that the Veteran reported experiencing symptoms of pain in the right knee on and off for twenty years. It was reported to be worsened by walking. X-ray was normal as to bones and soft tissue of the knee. The Veteran underwent VA examination in April 2002, shortly following the filing of his service connection claim. X-ray of the bilateral hips at that time showed the healed pelvic fracture, and showed normal hip joints bilaterally. The Veteran reported to the examination wearing a large brace on his right knee, and also reporting constant pain in his right hip. He also reported a recent fall due to hip and knee pain. The examiner reported that hip and knee examination was difficult due to the Veteran's refusal to turn over onto his abdomen and refusal to remove the right knee brace. The examiner noted that the Veteran's pelvic fracture "could easily have damaged the left hip, and subsequently resolved in the degenerative joint disease of the hip." There was no explanation of this stament. Further, the Board again notes that x-ray at that time revealed a normal hip, without degenerative changes. Thus, this VA examiner's opinion is flawed in that it is discussing a nexus for a disability specifically noted to not exist at that time. VA orthopedic notes in October 2002 show that the Veteran reported injuring the right knee in service in 1974, "at the same time with a fracture of his pelvis." The Board again notes that the pelvis injury occurred in 1973, and there is no evidence of in-service reports of a simultaneous right knee injury. In December 2002, the Veteran underwent arthroscopic surgery to repair medial meniscal tear of the right knee. Follow-up notes from 2013 show that he continued to wear a hinged brace. July 2003 notes show continuing reports of knee pain. However, a December 2003 physical examination report shows that the Veteran's joints had full range of motion, no pain and no contractures, with no atrophy or weakness. Several years later, in May 2007, the Veteran reported to a VA physician that he had recurrent left hip pain. The Veteran underwent VA examination of the joints again in June 2009. The examiner noted that while discussing the bilateral hip pain, the Veteran "points to his buttocks." The examiner went on to state that this "is the location of pain that is usually related from the lumbar spine rather than the hips. Hip pain is in the groin." The examiner also noted that the Veteran has no limitations due to his hips. As to the right knee, this examiner also noted report of injury in service "from jumping off platforms." Physical examination revealed range of motion to be normal, but to involve pain at the extremes of internal rotation. Examination of the right knee showed tenderness to palpation, but a stable knee with normal range of motion. The examiner diagnosed residuals of right knee medial meniscectomy and microfracture secondary to high grade chondromalacia of the knee. As to the hips, the examiner noted "normal bilateral hip examination." The examiner concluded that "[t]here is no evidence of any residual manifestations of the ilium fracture while in the military service." In November 2011, the Veteran again underwent VA examination of his hips and knee. The VA examiner at this time confirmed that May 2010 x-rays showed mild degenerative changes of the right hip. The Board notes, however, that the 2013 examiner (whose report is discussed below) suggests that the May 2010 x-ray was of both hips. The Veteran reported that this was diagnosed in active duty. The examiner did not report a diagnosis related to the left hip. As to etiology of the right hip arthritis, the examiner opined that it was less likely as not caused by the service-connected pelvic disability, and less likely as not caused by military service. The basis for this opinion was review of medical literature, review of the claims files, and the ongoing normal x-ray examination of the hips following service for many years, up until 2010. "It is a new finding many years after [active duty], there is no way that the changes could remain 'early' or mild if [the Veteran] had had this problem for 31 years. Primarily osteoarthritis is predominantly an age related condition, compounded by unknown/undocumented stresses/trauma of life and occupation over the long interval since leaving [active duty]." As to the right knee, the November 2011 VA examiner noted the diagnosis of degenerative joint disease with medial meniscus tear found in the June 2002 MRI report. The Veteran reported constant right knee pain and that "his right knee problem started in service." The examiner recognized his contentions that the current disability is due either to the service-connected pelvic fracture, or due to parachute jumps in service. The examiner opined that the Veteran's right knee degenerative joint disease with medial meniscus tear is less likely as not caused by or a result of his service-connected pelvic disability; and is less likely as not caused by or a result of his military service. The examiner explained that while the Veteran attributes his right knee condition to "jumping off platforms in service around 1974 when he was in jump school," ... "he reenlisted and was able to continue with his duties from 1976 until 1979 despite his claimed right knee condition." Moreover, the examiner noted that the Veteran was able to work for the postal service, which entailed constant walking for nineteen years after service. The abnormalities to the right knee were not noted until 2002, many years after active service, and were noted to be most likely due to aging and occupation. The most recent VA examination was conducted in May 2013. The examiner noted review of the claims files and also physically examined the Veteran. This examiner relied upon the May 2010 x-ray showing mild degenerative changes to the hips. This examiner noted that there was no evidence of painful motion of the right hip, but that painful motion began at 110 degrees of flexion of the left hip. This examiner also compared the May 2010 x-ray report showing "early degenerative changes" with the April 2002 x-ray report, which documented "normal hip joints bilaterally." Based upon this physical examination and review of the record, the May 2013 VA examiner concluded that neither the right or left hip disabiities were caused by the Veteran's military service. The examiner noted that there was "NO objective evidence" of right or left hip conditions onset in military service or shortly after discharge. It was not until 2010 that x-ray showed signs of "early osteoarthritis," which is "consistent with the aging process." Further, the examiner opined that the current left and right hip disabilities were not caused by or aggravated by the Veteran's service-connected pelvis disability. The examiner explained that for many years after the Veteran's separation from service, x-rays were normal as to the hips. The examiner also noted normal leg length discrepancy, normal wearing pattern to the shoes, and normal gait. The examiner, for these reasons, found no relationship between the service-connected pelvis disability and the current hip arthritis. The May 2013 examiner also confirmed the right knee meniscus tear, based upon June 2002 MRI, and right knee mild degenerative joint disease, based upon September 2007 x-ray. The Veteran reported that he injured his knee in a parachute jump in his first period of service during routine training in 1972-73, but noted that he did not seek treatment until 2002. The examiner determined that the Veteran's right knee degenerative joint disease was not caused by his military service because there was "NO objective evidence" of the onset of a knee disability in military service. Manifestations of a right knee disability onset in 2002, twenty-three years after service, at which time the Veteran was 53 years of age, making degenerative joint disease "consistent with the aging process." The examiner also opined that the Veteran's knee disability was not caused or aggravated by the service-connected pelvis disability. As with the hips, the examiner explained that for many years after the Veteran's separation from service, the knee was normal. The examiner also noted normal leg length discrepancy, normal wearing pattern to the shoes, and normal gait. The examiner, for these reasons, found no relationship between the service-connected pelvis disability and the current knee arthritis. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on his symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Although the Veteran is competent to describe his symptoms, whether the symptoms the Veteran experiences are in any way related to his current disabilities is a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Likewise, the Veteran does not have the medical expertise required to determine whether his hip or knee degenerative joint disease, or any other hip or knee disability, was incurred in service, incurred due to any in-service incident, or related to a service-connected disability. See Jandreau, 492 F.3d at 1376-77 (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the in-service pain, as reported by the Veteran and confirmed by the service treatment records, especially as it related to the left hip, can have many causes, and medical testing and medical expertise are needed to determine nature and etiology. The Board accepts that the Veteran experienced pain in service. However, this fact does not establish that the Veteran incurred arthritis of the right knee or either hip in service, or that the pain in service was the initial manifestation of the later diagnosed degenerative joint disease. Thus, the Board finds that the Veteran is not competent to render a medical opinion on the onset and etiology of his current hip or knee disabilities. The VA examiner's opinions are the only medical opinions, based upon a review of the complete claims file, addressing the relationship between the current disabilities and active service. Thus, such medical opinions are of greater probative value than the Veteran's lay contentions. Id. Further, the Veteran is making a claim that service connection is warranted based upon symptoms experienced in service, which have continued ever since. In that the current diagnosis is arthritis, the Veteran's statements appear to raise a claim for presumptive service connection for a chronic disease manifesting within one year of service under 38 C.F.R. § 3.309(a). The Veteran essentially contends that the pain he experienced during service was the initial notation of his current osteoarthritis. However, as noted above, the Veteran is not competent to report that the symptoms he experienced in service, or at any time after service, can be deemed the initial notations of arthritis. While the Veteran is competent to report that he experienced such pain in service, and the service treatment records show ongoing reports of such pain, the Veteran is simply not a medical professional such that he could be deemed competent to opine that the any pain experienced in service was arthritis. As noted above, the VA examiners have consistently reported that many years passed between the Veteran's service and the initial manifestation of degenerative joint disease, and these statements took into account the in-service notations of pain, and the Veteran's reported history. Thus, as a medical professional deemed x-rays required to assess the diagnosis, and noted that many x-rays between service and the later diagnoses were noted as normal, the Board finds that the Veteran's lay opinions are simply not competent to establish that the report of pain in service can be deemed a notation of arthritis in service. Moreover, the VA examiner considered the lay statements and was aware of the Veteran's reports of pain in service and since, but was unable to find that the current hip and knee degenerative joint disease initially manifested in service due to the paucity of evidence from the time of service for many years thereafter. Consideration of this claim on the basis of continuity of a chronic disease noted in 38 C.F.R. § 3.309 is, therefore, not warranted, as there was no notation of arthritis in service. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In conclusion, the competent evidence does not reveal a nexus to bilateral hip, or right knee, degenerative joint disease, or any other lower extremity disability, occurring in service. Further, the competent evidence does not indicate that the Veteran had an initial notation of arthritis during service or within the year following his separation. While the Board has considered the Veteran's lay contentions as to the etiology of his current disabilities, the Board has accorded greater weight to the balance of the probative medical evidence of record. Although the Veteran might sincerely believe that his lower extremity disabilities are related to service, he, as a layperson, is not qualified to render a medical opinion as to etiology or diagnosis. As such, service connection must be denied. 38 C.F.R. §§ 3.303, 3.307, 3.309. 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 Veteran's claim, that doctrine is not applicable concerning this issue. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to service connection for a disability of the bilateral lower extremities, including the right knee and both hips, to include as secondary to a service-connected pelvic fracture with right thigh numbness, is denied. ____________________________________________ L.M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs