Citation Nr: 1325383 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 09-46 313 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a left knee disability, to include and as secondary to or aggravated by service-connected bilateral pes planus. 2. Entitlement to service connection for a right knee disability, to include and as secondary to or aggravated by service-connected bilateral pes planus. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1948 to July 1967. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. This case was previously remanded by the Board in July 2011, December 2012, and March 2013 for additional development. The case has again been returned to the Board for further appellate consideration. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. A left knee disability, to include degenerative joint disease and osteoarthritis, was not manifest in service, was not manifest within one year of separation and is not related to service or caused or aggravated by service-connected bilateral pes planus with degenerative joint disease. 2. A right knee disability, to include degenerative joint disease, was not manifest in service, was not manifest within one year of separation and is not related to service or caused or aggravated by service-connected bilateral pes planus with degenerative joint disease. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability, to include degenerative joint disease and osteoarthritis, and as secondary to or aggravated by service-connected bilateral pes planus with degenerative joint disease, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for a right knee disability, to include degenerative joint disease, and as secondary to or aggravated by service-connected bilateral pes planus with degenerative joint disease, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, 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); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice 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. Notice should be sent prior to the appealed rating decision or, if sent after the rating decision, before a readjudication of the appeal. A supplemental statement of the case (SSOC), when issued following a notice letter, satisfies the due process and notification requirements for an adjudicative decision for these purposes. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided compliant VCAA notice to the Veteran in a September 2008 letter, prior to the October 2008 rating decision currently on appeal. The September 2008 letter explained what information and evidence was needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The letter also provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters on appeal. Pertinent medical evidence associated with the claims file consists of service treatment records, VA and private treatment records, the report of an August 2011 VA examination, and December 2012 and July 2013 VA addendum opinions. Although the Board has previously found the opinions provided by the August 2011 and December 2012 VA examiners to be inadequate due to the absence of an etiological opinion as to the issue of aggravation in the August 2011 opinion, lack of supporting rationale provided for the December 2012 opinion, and lack of consideration of relevant findings in-service findings pertaining to the right knee, the Board finds that the most recently obtained July 2013 addendum opinion, in combination and when considered with the other evidence of record, sufficiently address the Veteran's claims. The August 2011 examiner conducted an appropriate interview and evaluation of the Veteran, his service-connected bilateral pes planus disability, and his current bilateral knee disability. The July 2013 examiner reviewed the Veteran's past reported and documented medical history with regard to his service-connected and currently claimed disabilities and his current complaints and contentions. The July 2013 examiner rendered appropriate conclusions consistent with the remainder of the evidence of record. The Board, therefore, concludes that the August 2011 examination report and the July 2013 addendum opinion, in combination and when considered with the other evidence of record, are adequate for purposes of rendering a decision with respect to the issues decided herein. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In a July 2013 correspondence, the Veteran's representative contended that the July 2013 opinion is inadequate due to lack of supporting rationale provided by the examiner. For the reasons stated immediately above and discussed in detail below, however, the Board disagrees and finds that an additional remand for obtainment of a new examination or opinion is not necessary. As noted above, the Board remanded this case for obtainment of a VA examination with an etiological opinion in July 2011. In August 2011, the Veteran was afforded a VA examination and the claim was readjudicated in the September 2012 supplemental statement of the case (SSOC). The Board again remanded this case in December 2012 and March 2013 for obtainment of addendum etiological opinions pertaining to the claimed disabilities. The requested opinions were received in December 2012 and July 2013 and the claim was readjudicated in February and July 2013 SSOCs. Thus, there has been substantial compliance with its prior remand orders. See Stegall v. West, 11 Vet. App. 268 (1998) (duty to ensure compliance with Board remand order). Neither the Veteran nor his representative has identified any additional, relevant evidence that has not otherwise been requested or obtained. The Veteran has been notified of the evidence and information necessary to substantiate his claims, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claims. Finally, the Veteran has declined the opportunity to present testimony in support of his claims. Thus, the duties to notify and assist have been met. II. Legal Criteria The Veteran and his representative essentially contend that the Veteran's current bilateral knee disability is either: (1) directly related to service in that he stood for many hours on concrete during service as evidenced by development of service-connected pes planus during service, or alternatively; (2) caused or aggravated by his service-connected bilateral pes planus disability with subsequent development of degenerative joint disease in his feet, which is a progression of service-connected bilateral pes planus (see January 2006 examination report). In the March 2013 brief, the representative asserted or clarified the contention that the Veteran's bilateral knee disability is caused or aggravated by an altered gait or body mechanics due to service-connected bilateral pes planus with degenerative joint disease. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110; 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to show a 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2012). A recent decision of the U.S. Court of Appeals for the Federal Circuit (Federal Circuit Court), however, clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As arthritis and degenerative joint disease are disabilities noted under 38 C.F.R. § 3.309, the Veteran's disabilities are afforded the alternative method for establishing the required nexus between his current disability and service by asserting continuity of symptomatology since service. See Walker, supra. Service connection may also be granted on a presumptive basis for certain chronic diseases, including arthritis and degenerative joint disease, if they are shown to be manifest to a degree of 10 percent or more within one year following the Veteran's separation from active military service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Under 38 C.F.R. § 3.310(a), service connection may also be granted for disability that is proximately due to or the result of a service-connected disease or injury. Such permits a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation to a nonservice-connected disability by a service-connected disability. Id. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. In certain circumstances lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both 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"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308 - 09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376 -77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. III. Factual Background The Veteran's service treatment records show that he was seen for effusion of his right knee in March 1956. During a June 1959 periodic medical evaluation, there was an initial notation of a 1 inch linear scar on his right knee. During reenlistment examination in May 1962 and an annual examination in April 1964, there were no foot or knee complaints and examination of the feet and knees was normal. On retirement examination in February 1967, the Veteran reported foot trouble with support and pain up his legs. With the exception of the scar on his right knee, examination of his feet and knees was normal. During VA examination in December 1987, the Veteran complained of flat feet. He reported that he worked in the mess hall during service which required that he stand on concrete for 10 to 12 hours a day. Subjective complaints included foot pain, without mention of knee or leg pain, after standing on concrete for more than 1 hour. Objective findings on examination included minimal bulging of the medial borders of the feet and some depression of the longitudinal arch. His gait, posture, and function were essentially normal. Diagnostic impression was pes planus with essentially no functional disability, but with some intolerance of standing on hard surfaces for more than 1 hour. In March 1988, service connection was granted for bilateral pes planus. On VA examination of the Veteran's service-connected bilateral pes planus disability in March 1991, it was noted that the Veteran's post-service employment required that he sit for long periods, during which he experienced very few symptoms in his feet. "Only in recent years," he reportedly began to develop "severe pain in his legs and feet again." If he was forced to stand in one position for longer than one hour, he would develop a cramping and burning sensation in his feet that radiated up the posterior aspect of the legs and into the hip regions. A 100 pack year smoking history was noted with the Veteran quitting three years prior. Objective findings on examination of the feet included a grade 3 or 4 bilateral pes planus involving both the longitudinal and transverse arches and some pronation of the feet with minimal angulation of the Achilles tendon. The examiner found that some of the Veteran's described discomfort in the feet could be associated with the loss of the normal architecture; however, the burning sensation radiating up the legs was suggestive of a vascular element to his symptoms. A May 1998 VA treatment record showed complaints of pain in the feet and legs. It was noted that he was known to have bilateral pes planus. During a January 2006 VA QTC examination of his service-connected bilateral pes planus, complaints included flat feet, toe cramping, pain and weakness at rest, and an inability to stand or walk for long periods due to stiffness, swelling, and fatigue. Significantly, examination of the feet did not reveal any signs of abnormal weight bearing, tenderness, weakness, edema, atrophy, or disturbed circulation. His posture and gait were normal. His feet appeared normal while in supine and flattened slightly with standing and pronation, left greater than right. In August 2008 the current claim for a bilateral knee condition was received. The Veteran asserted that his service-connected bilateral pes planus had altered his gait and resulted in a current bilateral knee condition. Following a VA feet examination of his service-connected bilateral pes planus disability in September 2008, the examiner diagnosed bilateral pes planus with degenerative joint disease, mild in degree, with zero to minimal loss of function. In July 2009, the Veteran submitted private MRI examination reports of his bilateral knees. Diagnostic impressions of the right knee included posterior horn medial meniscus tear, grade III chondromalacia of the patella and medial compartment; tiny joint effusion; small popliteal fosse cyst, and; a metallic artifact from unknown source. Diagnostic impressions of the left knee included medial meniscus tears; chondromalacia; small joint effusion with mild synovitis; osteoarthritis, and; mild prepatella soft tissue swelling. In August 2011, the Veteran was afforded a VA examination of his knees and feet to determine the nature and etiology of his claimed bilateral knee disability. At the time of examination, he was 81 years old with a currently diagnosed bilateral knee condition with mild degenerative changes. A 20 year military history was noted with retirement in 1967. The Veteran reported a "long history" of aching and giving way of his bilateral knees, but denied any specific injury to either knee during or after service. He believed that his current knee disability was due to prolonged standing on his feet during military service. Diagnostic impression was mild degenerative joint disease of the left knee. X-ray examination of the right knee was suggestive of mild arthritis with joint space narrowing in the medial compartment of the knee joint. A radiopaque foreign body in the soft tissues of the proximal right leg projected over the right proximal tibia was also present. Diagnostic impression was marginal degenerative joint disease with foreign body in the soft tissue. As to the Veteran's feet, the August 2011 examiner noted that the Veteran complained of foot pain on prolonged standing and walking. Movement of his feet and ankles was non painful and range of motion was within normal limits. Following a review of the claims file, the August 2011 VA examiner opined that the Veteran's bilateral degenerative knee condition was less likely than not (less than 50 percent probability) incurred in or caused by an in-service event, injury, or illness. She reasoned that there is no evidence of any trauma or injury to either knee during service and retirement examination in 1967 was negative for a finding of any knee condition. She further opined that the Veteran's degenerative condition of his bilateral knees is less likely than not (less than 50 percent probability) due to or the result of his service-connected bilateral pes planus with degenerative joint disease. She reasoned that pes planus does not cause degeneration in the knees. She opined that the Veteran's degenerative condition of his bilateral knees is most likely secondary to his age, occupation and post-service events/or injuries. In accordance with the Board's December 2012 remand, an addendum opinion was obtained from a different VA examiner in December 2012 as to whether the Veteran's current bilateral knee disability may be aggravated by his service-connected bilateral pes planus with degenerative joint disease. The December 2012 VA examiner opined that the Veteran's bilateral knee conditions less likely as not are not aggravated by his service-connected pes planus and are at least as likely as not the result of his age, occupation and post-service events/or injuries. No supporting rationale was provided. As noted in the March 2013 remand, the August 2011 and December 2012 etiological opinions contained no mention of in-service findings of right knee effusion and a 1 in scar on the right knee. Accordingly, the claims file was returned to the December 2012 examiner for obtainment of an addendum etiological opinion as to all theories of entitlement to service connection for the Veteran's claimed bilateral knee disability. The requested opinion was received in July 2013. The examiner documented his through review of the claims file, to include all relevant findings in the Veteran's service and post-service treatment records and examination reports. Thereafter, as to direct service connection, the examiner opined that the Veteran's current bilateral knee disability is less likely as not related to any event, injury, or illness during military service. He found that right knee effusion during service in March 1956 is less likely as not related to post-service findings of a retained metallic foreign body in the right knee. He reasoned that the current retained foreign body in the right knee is shown on radiographic examinations to be in the soft tissue of the right knee, not the joint. He found that effusion in March 1956 was related to a joint condition which was not present on subsequent service examinations. Thus, he concluded that that the right knee joint effusion during service in March 1956 and post-service findings of a retained metallic foreign body in the right knee are unrelated. As to the 1 inch scar on the right knee, initially noted during an April 1966, the July 2013 examiner opined that it is less likely as not associated with the March 1956 right knee effusion and at least as likely as not a result of factors unrelated to the foreign body noted on subsequent radiographic examinations of the right knee. He reasoned a penetrating injury significant enough to produce a 1 inch laceration would be an incident recalled by the Veteran. Thus, the right knee scar noted during service is at least as likely as not related to some superficial injury similar to the incident that resulted in the 2 inch right arm linear scar noted during the same in-service examination. The examiner further opined that the Veteran's current right knee disability is less likely as not caused or aggravated by any alleged injury that resulted in the retained foreign body or the presence of the retained foreign body and at least as likely as not the result of factors unrelated to the retained foreign body. He opined that the retained foreign body has not altered or worsened the Veteran's current right knee disability. He reasoned that x-rays show a retained foreign body in the soft tissues of the right knee as opposed to the knee joint. Thus, the current meniscus tear and arthritis of the right knee are unrelated to the retained foreign body in the right knee. As to the Veteran's complaints of foot pain with radiation up the leg on separation examination in February 1967, the examiner opined that such complaints are less likely as not related to the current bilateral knee disabilities of meniscus tears and mild arthritis. He stated that such complaints are at least as likely as not a result of a transient complaint and not caused and/or worsened by the Veteran's service-connected bilateral pes planus with degenerative joint disease. The examiner reasoned that the Veteran's report on VA examination in March 1991 that he had experienced few foot symptoms with return of such complaints only in recent years was evidence against a finding of chronic disability during service. Moreover, a torn meniscus or arthritic condition with onset during service would have been a chronic and ongoing condition that would not have improved until the late 1980s. As to secondary service connection, the examiner opined that the Veteran's current bilateral knee disability is less likely than not due to, the result of, or permanently aggravated by his service-connected bilateral pes planus with degenerative joint disease. Rather, he opined that the Veteran's current bilateral knee disability is at least as likely as not a result of age-related changes. The examiner reasoned that while foot abnormalities may affect the proximal lower extremity joints by gait alterations and abnormal weight bearing, prior VA examinations of the Veteran's feet and lower legs dated in March 1991 and 2006 were negative for any evidence of an abnormal gait or weight bearing. Moreover, the Veteran's ankles would be effected initially, however, examination of his ankles had been normal on all occasions and there had been no mention of ankle complaints, which weighs against a finding that the Veteran's current bilateral knee conditions are related to or caused or aggravated by his service-connected bilateral pes planus disability with degenerative joint disease. IV. Analysis On review, the Board finds that service connection is not warranted for a current disability of either knee under any theory of entitlement. July 2009 bilateral knee MRI findings and x-ray findings during the August 2011 VA examination show that the Veteran currently has degenerative joint disease and arthritis of his left knee and degenerative joint disease of his right knee and bilateral meniscus tears. Thus, the issue for consideration on appeal is whether the Veteran's current bilateral knee disabilities were incurred in service or otherwise related to any event, injury, or illness therein, whether degenerative joint disease or arthritis of either knee manifested to a compensable degree within 1 year of discharge from active service, or whether current disability of either knee is caused or aggravated service-connected bilateral pes planus with degenerative joint disease. As the only radiographic findings showing degenerative joint disease and/or arthritis of either knee are dated in July 2009 and August 2011, there is simply no evidence that the Veteran's current degenerative joint disease and/or arthritis of either knee manifested to a compensable degree during service or within 1 year of his discharge. Thus, service connection for chronic arthritis and/or degenerative joint disease on a presumptive basis is not warranted. See 38 C.F.R. §§ 3.307, 3.309. In addition, the medical evidence does not show that chronic disability of either knee was incurred during or is directly related to any incident of the Veteran's military service. With the exception of effusion of the right knee on a single occasion in March 1956, and a notation of a 1 inch scar on the right knee initially noted on a June 1959 service examination, the Veteran's service treatment records and examination reports, to include on multiple occasions subsequent to the March 1956 and June 1959 findings of right knee effusion and a right knee scar, are negative for any complaints, findings, or diagnosis pertaining to either knee. Also, during VA examination in August 2011, the Veteran explicitly denied any history of injury to either knee during or after military service. The United States Court of Appeals for the Federal Circuit has held, however, that a claimant is not precluded from establishing service connection with proof of actual causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). On review of the record as a whole, however, there is simply no evidence showing that the Veteran's current disabilities of either knee, to include degenerative joint disease and osteoarthritis, may be related to any event, injury, or illness during service. The July 2013 VA medical opinion concludes that in-service findings of right knee effusion on one occasion in March 1956, a single complaint of foot pain with radicular pain up the legs on retirement examination, and in-service notation of a right knee scar with post-service radiographic findings of a retained foreign body in the soft tissue of the right knee, are ultimately unrelated to the Veteran's current degenerative condition and meniscus tears of his bilateral knees. The July 2013 examiner also opined that the Veteran's current bilateral knee disabilities are not caused or aggravated by the Veteran's service-connected bilateral pes planus with degenerative joint disease and any claimed altered body mechanics as a result. Such conclusions are overwhelmingly supported by the evidence of record and by the rationale provided by the July 2013 medical opinion. Despite ample opportunity to submit evidence to the contrary, the Veteran has not done so. The Board further notes that the July 2013 medical examiner related the Veteran's current bilateral knee disabilities to his age (81 years old at the time of the August 2011 VA examination) and his post-service employment and activities. The Board observes that such conclusion is consistent with findings contained in a 1998 VA treatment record, which shows a history degenerative arthritis of the bilateral shoulders without history of a back injury and x-ray findings at that time also showed osteoarthritis of the dorsal spine (spur formation). Moreover, the Veteran has not presented any evidence showing that he has experienced a chronic disability of either knee or continuous symptomatology since his discharge from active service. In fact, as noted in the July 2013 opinion, continuous symptomatology of a knee disability of either knee is countered by the Veteran's own self report during VA examination in 1991, more than 20 years after discharge, that in-service complaints of foot and leg pain had only recently recurred. It is notable that such complaints were absent of any reference to either knee. There is no post-service evidence of disability of either knee dating prior to the Veteran's claim for service connection for such in 2008, more than 40 years following his discharge from active military service. In this regard, evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claims. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Furthermore, the record does not contain competent lay evidence of continuity of symptomatology such as to overcome such gap in time. Indeed, although the Veteran submitted claims for VA service-connected disability compensation and increased compensation as early as 1987 pertaining to his service-connected bilateral pes planus disability, his claims, treatment records, and VA examination reports pertaining to those claims dated in 1987, 1991, 2006, and 2008 are notably absent for any complaint, finding, or diagnosis of a disability of either knee. Finally, in his August 2008 claim for service connection, the Veteran asserted that his currently claimed bilateral knee disability is related to an alleged gait alteration that be believed resulted from his service-connected bilateral pes planus disability as opposed to any event or injury during service. As noted, the Board is cognizant that service treatment records do reflect two or three instances of complaints or findings pertaining to the right knee during service. However, as discussed, VA health care providers have determined that these instances and findings are unrelated to any current disability of either knee. In this regard, the Board is mindful of the decision in Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006), wherein the Court determined that the Board erred by finding that a claimant's report of in-service symptoms lacked credibility solely because there was no objective medical evidence corroborating those symptoms at the time. The Board finds, however, that the Court's holding in Buchanan is not applicable in the instant case as the Veteran has not specifically alleged, and the evidence of record clearly contradicts, any potential assertion of continuity of symptomatology pertaining to disability of either knee since the Veteran's discharge from military service. Having found that there is no evidence of a continuity of symptomatology of a disability of either knee since service, the Board finds that the Veteran, as a lay person, is not otherwise competent to link his current bilateral knee disabilities to either in-service injury or symptoms he experienced in service. Therefore, the Board finds the conclusions of the July 2013 VA examiner discussed above to be the most probative evidence on the issue of whether the claimed knee disabilities are related to service or service-connected disability. The Board acknowledges the Veteran's sincere belief that his current bilateral knee disabilities are caused or aggravated by his service-connected bilateral pes planus with degenerative joint disease. As a layperson, however, his own assertions attributing his current bilateral knee disability to his service-connected bilateral pes planus with degenerative joint disease is not competent evidence. This is a medical question requiring medical expertise. In reaching the conclusions above the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the appellant's claims, service connection for the claimed disabilities must be denied. 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 left knee disability, to include as secondary to or aggravated by service-connected bilateral pes planus with degenerative joint disease, is denied. Entitlement to service connection for a right knee disability, to include as secondary to or aggravated by service-connected bilateral pes planus with degenerative joint disease, is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs