Citation Nr: 1326381 Decision Date: 08/19/13 Archive Date: 08/26/13 DOCKET NO. 11-12 957 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon THE ISSUES 1. Entitlement to service connection for degenerative arthritis and meniscal tear of the right knee, claimed as secondary to degenerative arthritis of the left knee. 2. Entitlement to service connection for status post chronic lumbar spine strain with degenerative arthritis, claimed as secondary to degenerative arthritis of the left knee. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran served on active duty from February 1976 to February 1980. This appeal to the Board of Veterans' Appeals (Board) arose from a November 2008 rating decision in which the RO denied service connection for right knee and low back disorders. In October 2009, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in March 2011, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in May 2011. In his May 2011 substantive appeal (VA Form 9), the Veteran requested a Board hearing before a Veterans Law Judge at the RO. In July and August 2012 correspondence, he was notified that his Board hearing had been scheduled for a date in September 2012. Although the hearing notification was not returned by the U.S. Postal Service as undeliverable, the Veteran failed to report for the scheduled hearing. In correspondence sent later in September 2012, the Veteran wrote that he missed his scheduled hearing because he was being evicted from his apartment and was now homeless. However, the Veteran did not request another hearing and, in fact, requested that his case be advanced on the Board's docket. Under these circumstances, his Board hearing request has been deemed withdrawn. See 38 C.F.R. § 20.704(d) (2012). In November 2012, a Deputy Vice Chairman of the Board granted the Veteran's motion to advance this appeal on the Board's docket, pursuant to 38 U.S.C.A. § 7107(a)(2)(C) (West 2002) and 38 C.F.R. § 20.900(c) (2012). In January 2013, the Board remanded the claims on appeal to the RO, via the Appeals Management Center (AMC) in Washington, DC, for further action, to include additional development of the evidence. After completing the requested development, the RO/AMC continued to deny the claims (as reflected in a June 2013 supplemental SOC (SSOC)) and returned these matters to the Board for further appellate consideration. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals VA outpatient treatment records dated through February 2013 which were considered by the RO in the most recent June 2013 supplemental statement of the case. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim on appeal have been accomplished. 2. There is no evidence or allegation that current right knee disability had its onset in, or is otherwise medically related to, service, and the most persuasive evidence on the question of the etiology of current right knee disability establishes that such disability was not caused or worsened by the Veteran's service-connected left knee disability. 3. There is no evidence or allegation that current low back disability had its onset in, or is otherwise medically related to, service, The most persuasive evidence on the question of etiology of current low back disability establishes that such disability was not caused or worsened by the Veteran's service-connected left knee disability. CONCLUSIONS OF LAW 1. The criteria for service connection for degenerative arthritis and meniscal tear of the right knee, claimed as secondary to degenerative arthritis of the left knee, are not met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.159, 3.303, 3.310 (2012). 2. The criteria for service connection for status post chronic lumbar spine strain with degenerative arthritis, claimed as secondary to degenerative arthritis of the left knee, are not met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102 , 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R § 3.159(b)(1) . The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 - 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service (or service-connected disability) and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, in an October 2008 pre-rating letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the claims for service connection, what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. The November 2008 RO rating decision reflects the initial adjudication of the claims after issuance of the October 2008 letter. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Pertinent medical evidence associated with both the paper and electronic claims file consists of service treatment records, post-service private and VA treatment records, the August 2008 statement from the Veteran's treating physician Dr. M.N.D., a VA staff physician, the February 2011 VA examination report and December 2011 addendum, and the April 2013 VA examination report. Also of record and considered in connection with the appeal is the various written statements provided by the Veteran, and by his representative, on his behalf. The Board finds that no additional RO action to further develop the record in connection with either claim, prior to appellate consideration, is required. The Board finds that the VA examinations and medical opinions obtained in connection with these claims are adequate for and pertinent to its determinations. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In particular, the April 2013 examiner's opinion was based upon physical examination of the Veteran and complete review of the claims file, and was supported by fully explained medical and factual bases. Under these circumstances, the Board finds that no additional examination or opinion is needed to decide these claims. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate the claims, the avenues through which she might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with any claim herein decided. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters on appeal, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Factual Background Service treatment records are negative for right knee and/or low back problems. A January 1980 separation examination shows a normal spine and normal lower extremities. Post-service VA treatment records show X-ray findings of mild bilateral tricompartmental degenerative joint disease of the right knee as early as August 2007 and magnetic resonance imaging (MRI) findings of right knee medial meniscus tear as early as April 2008. A May 2008 VA treatment record notes that the Veteran was involved in a motor vehicle accident in March 2008 which resulted in a "worsening" of neck and back pain. An August 2008 VA treatment record notes continued low back pain as well as DJD (degenerative joint disease) on film. The Veteran is currently service connected for tinnitus, a scar of the left wrist status post carpal tunnel surgery, carpal tunnel syndrome of the left wrist, degenerative arthritis of the left knee, and residuals of a pilonidal cystectomy. The Veteran filed a claim for service connection for right knee and low back disorders in September 2008. In connection with this claim the Veteran included an August 2008 statement signed by his treating physician Dr. M.N.D., a VA staff physician. Dr. M.N.D. noted that the Veteran suffered from chronic left knee pain, which started back in 1978 with a left knee injury during military service. He also more recently developed right knee pain, and was found to have a medial meniscal tear which will require surgical repair. Both knees are painful with walking and the Veteran has found that he is more and more limited in his ability to ambulate. The Veteran also suffered from intermittent low back pain, which worsened as of March 2008 when he was involved in a motor vehicle accident. X-rays of his back show mild to moderate arthritis changes, and his pain issues seem to stem from a combination of this and musculoskeletal pain. His back pain symptoms had not improved greatly from the time of his accident, and he now falls into the realm of having chronic back pain. Dr. M.N.D. wrote that the Veteran's knee pain issues impact his back pain, and his service-connected left knee issues have contributed to the development of chronic intermittent back pain. Furthermore, Dr. M.N.D. opined that it was likely that gait changes due to his service-connected left knee disorder may have contributed to his current right knee pain. At the time of the Veteran's claim for right knee and low back disorders, service connection was not yet in effect for the left knee. Following the November 2009 rating decision which granted service connection for the left knee, the Veteran was scheduled for a VA examination in February 2011. The February 2011 VA examiner, Mr. W.K.R. is a PA-C (physicians assistant-certified). With regard to the low back the examiner noted that Veteran had a diagnosis of status post chronic lumbar spine strain with degenerative changes confirmed on x-rays to rule out any bony abnormalities. This is not at least as likely as not related to service as the Veteran was overweight and worked in the maintenance industry where he had to lift, carry, climb, and do stairs on a daily basis with physical laborious work. The examiner found no evidence to indicate that any compensatory mechanism had injured the Veteran's lumbar spine and he had a motor vehicle accident resulting in back complaints in 2008 confirmed in review. Therefore, the examiner opined that it was not at least as likely as not that the low back disorder was related to the service-connected left knee disorder. With regard to the right knee the examiner diagnosed bilateral degenerative arthritic knees with meniscal tears, both confirmed by MRI and CPRS review. It was noted that the Veteran has obvious degenerative changes bilaterally by MRI. This was more consistent with his weight and his occupation than it was for any compensatory mechanism. Once again, the examiner wrote that the right knee and lumbar spine were not at least as likely as not related to the Veteran's military service. The examiner so no compensatory mechanism to cause these degenerative changes. In a November 2011 VA Form 646, the Veteran's representative argued that more weight should be afforded the August 2008 opinion over the February 2011 opinion, as the August 2008 opinion was given by a medical doctor and the February 2011 opinion was given by a physician's assistant. The representative further argued that the February 2011 VA opinion that the Veteran's right knee and low back disorders are more likely due to his job and his weight than his service-connected left knee disorder did not make sense. It was noted that the Veteran was required to work and was unable to remove his left leg to do so. Therefore, he must use both of his lefts together. However, because of his service-connected left leg, he favors the left knee/leg and uses his right leg to take the brunt of the use. This has caused the right knee to degenerate. The Veteran's representative wrote that it was silly to that that the Veteran would not do this and therefore could not have an effect on the right knee. In December 2011, the claims file was sent to the same examiner who performed the February 2011 VA examination for an addendum to determine whether the Veteran's low back and/or right knee disorders are "at least as likely as not" permanently aggravated beyond natural progression by the degenerative arthritis of the left knee. In a December 2011 addendum, the VA examiner, Mr. R.M.W., PA-C, opined that it was less likely than not (less than 50 percent probability) that the Veteran's low back and right knee disorders were related to his military service. The examiner wrote that the Veteran is overweight and has bilateral knee meniscal tears without injury to the right knee in the service and during examination there was no evidence that the Veteran had mechanism to favor or cause overuse strain. Instead, the examiner wrote that the more likely reason was the Veteran's weight. The Veteran was, notably, a large man with increased weight that increased the stress on his bilateral knees. The lumbar spine was in a motor vehicle accident that increased the Veteran's pain and symptoms. This was referred to in the August 2008 letter and the knee symptoms are bilateral at the knees. Therefore, the examiner opined that the knees are not the cause of the aggravation. Rather, the Veteran's weight and accident are the cause of the aggravation. Mr. R.M.W. also opined that it was less likely than not (less than 50 percent probability) that the Veteran's low back and right knee disorders were related to the Veteran's service-connected left knee disorder. The examiner wrote that there was no connection to the back and left knee. The left knee is not the only symptomatic knee, the Veteran was bilaterally painful, and this was consistent with degenerative changes caused by increased weight as the knees see five to 10 times a persons body weight during activity and 50 pounds overweight is the stress that would be expected to cause the degenerative changes in the lumbar spine and right knee. The lumbar spine was injured in an accident and this was the cause and the only aggravation is from his weight as no mechanism was found during the examination to cause right knee pain or low back pain from the left knee. Mr. R.M.W. wrote that the Veteran's weight alone was enough to cause chronic strain on both right knee and lumbar spine. The post-service accident increased or caused the lumbar pain, therefore, there was no way of describing baseline as they were never expected to be normal. Mr. R.M.W. concluded that, in his opinion, there was no mechanism to cause the right knee or lumbar spine pain from the left knee. He did have elevated weight status and a motor vehicle accident that could give cause. Therefore, Mr. R.M.W. found no aggravation or cause from the left knee to the lumbar spine or right knee. In January 2013, the Board noted that while the February/December 2011 VA examiner concluded that the Veteran's current right knee and low back disorders were not secondary to and/or aggravated by his service-connected left knee disorders, these opinions were, notably, given by a physician's assistant rather than a medical doctor. Furthermore, the February 2011 opinion that the low back and right knee disorders are related to the Veteran being overweight/his occupation in the maintenance industry does not refute the Veteran's allegation that the right knee and low back disorders are secondary to or aggravated by his service-connected left knee disorder. Also, while these opinions note that there is no evidence of a "mechanism to favor" the service-connected left knee they do not explain what would constitute satisfactory evidence of "mechanism to favor." The Board noted that, in the August 2008 statement, Dr. M.N.D. opined that the Veteran's service-connected left knee issues have contributed to the development of chronic intermittent back pain and further opined that it was likely that gait changes due to his service-connected left knee disorder may have contributed to his current right knee pain. The Board found that this opinion was insufficient to grant service connection for right knee and low back disorders. While Dr. M.N.D. opined that the Veteran's service-connected left knee disorder has contributed to his current right knee and low back disorders she did not state in what way the Veteran's service-connected left knee disorder has contributed to the right knee/low back disorders. Thus, the Board requested that, on remand, clarification be sought from Dr. M.N.D. (a VA physician at the Portland VA Medical Center) regarding her August 2008 statement. Significantly, the Board noted that should Dr. M.N.D. be unavailable, or it is determined that another examination is needed, the RO should arrange for the Veteran to undergo examination, by an appropriate physician, to obtain an opinion in the case. Pursuant to the January 2013 Board remand, the Veteran was afforded a new VA examination in April 2013. Notably, this examination was not performed by Dr. M.N.D. and was, instead, performed by Dr. C.E.H. Significantly, it was noted that the opinion was being given on behalf of Dr. M.N.D. who does not perform Compensation and Pension examinations. This examination report shows that the examiner reviewed the claims file. Dr. C.E.H. noted that the Veteran had multi-level degenerative disc disease of the lumbosacral spine as the cause of the Veteran's spine disability. The examiner also noted that the Veteran had bilateral, mild degenerative joint disease as well as bilateral meniscal tears that were operated. It was noted that the Veteran had spent 15+ years (until August 2010) working in maintenance of a large complex during which time he was involved in significant physical activities such as installation and maintenance of plumbing and large appliances. In order for the left knee to be causing a permanent disability of the right knee and the lumbosacral spine, there would need to be a long-term severe gait disturbance from the left knee. The notes do not show this. Dr. M.N.D.'s notes did not reflect that the Veteran had a chronic gait disturbance from the left knee. In the various orthopedic and physical therapy notes, the Veteran's gait was often described as normal. Other times he was described as having an antalgic limp (i.e., due to back pain) from the right knee, from both knees, or from his back. During the April 2013 VA examination the Veteran seemed to have a mild antalgic (i.e., caused by pain) limp that was due to his back and both knees being stiff and sore when he arose from sitting. Reading through the notes, Dr. C.E.H. noted a clinical picture of back pain occurring after lifting heavy items and later getting worse after being involved in a car accident. The notes show a right knee condition arising in approximately 2007, with no suggestion that it was caused by an abnormal gait from the left knee. The documentation did not support a clinical picture of someone had had an ongoing severe gait disturbance due to the left knee. Dr. C.E.H. noted that degenerative joint disease and degenerative disc disease are caused by aging, which would be accelerated by obesity and repetitive injuries. Similarly, and for the same reasons, Dr. C.E.H. wrote that the lumbosacral spine degenerative disease and right knee degenerative joint disease were not permanently aggravated by the Veteran's service-connected left knee disorder. III. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases to include including arthritis (degenerative joint disease), shall be presumed to have been incurred in service if manifested to a compensable degree within a prescribed period post service (10 percent and one year, respectively, for a psychosis), even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307) 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 attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit recently clarified that the provisions of 38 C.F.R. § 3.303(b) pertaining to the award of service connection on the basis of continuity of symptomatology apply to chronic diseases as defined in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As noted, arthritis is among the diseases listed in section 3.309(a). 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. That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation to a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310 (2012). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Effective October 10, 2006, VA amended 38 C.F.R. § 3.310 with regard to the requirements for establishing secondary service connection on an aggravation basis. See 71 Fed. Reg. 52,744 - 47 (Sept. 7, 2006). Considering the pertinent evidence of record in light of the governing legal authority, the Board finds that each claim on appeal must be denied. In this case, the Veteran has not contended, and the evidence does not show, in-service complaints, findings, or diagnoses pertaining to the right knee or low back. While service treatment records show complaints of left knee pain with impressions of torn cartilage of the left knee, mild chondromalacia, and strain of ligaments, as early as March 1979, these records are negative with regard to complaints of the right knee or low back. Significantly, a January 1980 separation examination shows a normal spine and normal lower extremities. Rather, in this case, in September 2008, the Veteran filed a claim for service connection for right knee and low back disabilities as secondary to his in-service left knee injury and resulting disability, and the claims have been developed as ones for secondary service connection. As noted, post-service VA treatment records document X-ray findings of mild bilateral tricompartmental degenerative joint disease of the right knee as early as August 2007 and MRI findings of right knee medial meniscus tear as early as April 2008. A May 2008 VA treatment record notes that the Veteran was involved in a motor vehicle accident in March 2008 which resulted in a "worsening" of neck and back pain. An August 2008 VA treatment record notes continued low back pain as well as DJD on film. The Board notes that the record contains conflicting medical opinions on the question of whether the Veteran's current right knee and low back disabilities are related to his service-connected left knee disability. On one hand, in the August 2008 statement Dr. M.N.D. indicated that the Veteran's service-connected left knee disorder has contributed to his current right knee and low back disorders. On the other hand, the February/December 2011 as well as April 2013 VA examiners opined that the Veteran's current right knee and low back disabilities are less likely than not related to the service-connected left knee and were instead more likely related to the Veteran's post-service occupational history, his post-service accident, and his weight. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. See also Obert v. Brown, 5 Vet. App. 30 (1993); Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the August 2008 statement from Dr. M.N.D. indicates that the Veteran's service-connected left knee disorder has contributed to his current right knee and low back disorders, she did not explain this statement. The Board notes that the phrase "contributed to" falls short of the requirement that the disability for which service connection is short be "proximately due to" or "the result of" the service-connected disability (on the basis of causation or aggravation) contained in 38 C.F.R. § 3.310. Furthermore, there is no clearly-stated explanation of, or rationale for, the opinion, and it does not appear that Dr. M.N.D. had an opportunity to review the claims file, and, significantly, to review the Veteran's post-service occupational history as well as his post-service accident. While failure to review the claims file is not fatal to the opinion (see Nieves-Rodriguez, 22 Vet. App. at 304), consideration of the relevant history is a factor in assessing the probative value of medical opinions. By contrast, the Board finds highly probative the opinion of the April 2013 VA examiner on the medical nexus question. In the April 2013 VA opinion, Dr. C.E.H. noted the Veteran's 15+ year history of post-service significant physical activities such as installation and maintenance of plumbing and large appliances, found that there was no evidence of long-term severe gait disturbance from the left knee and found that the Veteran's lumbosacral spine degenerative disease and right knee degenerative joint disease were not caused by or permanently aggravated by the Veteran's service-connected left knee disorder. The Board notes that the April 2013 examiner rendered this opinion after thoroughly reviewing the claims file and medical records and examining the Veteran. Importantly, the examiner took into account the pertinent post-service history. The examiner also provided a rationale for his opinion; stating that there was no evidence of long-term severe gait disturbance. He also stated that the Veteran has been employed in a physically demanding position for years, and noted that the current disability could be related to his civilian occupation or post-service accident. Consistent with the April 2013 opinion, the February 2011/December 2011 VA examiner also opined that the Veteran's right knee and low back disabilities were not proximately caused by or aggravated by the Veteran's service-connected left knee disorder. Significantly, Mr. R.M.W. noted that there was no mechanism to cause the right knee or lumbar spine pain from the left knee and opined that the Veteran's post-service employment, his post-service motor vehicle accident , and his elevated weight status most likely were the cause of his right knee and low back disabilities. Thus, the most persuasive medical opinion evidence on the question of etiology of current right knee and low back disabilities weighs against each claim. Furthermore, to whatever extent the Veteran attempts to establish, on the basis of his own assertions, that there exists a medical relationship between current right knee and low back disabilities and service-connected left knee disability. such attempt must fail, Matters of diagnosis and etiology of the complex disabilities here at issue are matters within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). The Veteran is not shown to have the medical training or expertise needed to render a probative opinion on such a medical matter. See, e.g., Bostain v. West , 11 Vet. App. 124, 127 (1998); Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Hence, the lay assertions in this regard have no probative value. For all the foregoing reasons, the claims for secondary service connection for right knee and low back disabilities must be denied. In reaching the conclusion to deny each claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each 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). (CONTINUED ON THE NEXT PAGE) ORDER Service connection for degenerative arthritis and meniscal tear of the right knee, claimed as secondary to degenerative arthritis of the left knee, is denied. Service connection for status post chronic lumbar spine strain with degenerative arthritis, claimed as secondary to degenerative arthritis of the left knee, is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs