Citation Nr: 1326969 Decision Date: 08/22/13 Archive Date: 08/29/13 DOCKET NO. 04-31 982 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for a left knee disability, to include as secondary to a service-connected right ankle disability. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1978 to August 1985. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2003 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which, in relevant part, denied the benefit sought on appeal. Jurisdiction over the Veteran's appeal has since been transferred to the RO in Montgomery, Alabama. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in August 2007. A transcript of that hearing is of record. The Veteran's left knee disability claim on appeal was previously remanded by the Board for further evidentiary development in November 2007, March 2009, September 2009, May 2012, and March 2013. Multiple other service connection claims were disposed of in these prior Board decisions. FINDINGS OF FACT 1. Service connection is in effect for a right ankle sprain. 2. The Veteran does not have a current left knee disability that was at least as likely as not incurred during or as a result of active service. 3. The Veteran does not have a current left knee disability that is at least as likely as not proximately due to, or aggravated by, the service-connected right ankle disability. CONCLUSION OF LAW The criteria for entitlement to service connection for a left knee disability, to include as secondary to a service-connected right ankle disability, have not been met. 38 U.S.C.A. §§ 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 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 any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); 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. See 38 C.F.R. § 3.159(b) (2012). This notice must be provided prior to an initial unfavorable decision on the claim by the Agency of Original Jurisdiction. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA requires notice of what information and evidence not previously provided, if any, that is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). A February 2003 VCAA letter from the RO informed the Veteran of the elements required to substantiate a service connection claim for a left knee disability on a direct bases in accordance with 38 C.F.R. § 3.159(b). An additional VCAA letter was provided to the Veteran in June 2004. Subsequently, Dingess compliant notices were provided to the Veteran in March 2006 and October 2009. Finally, a March 2013 VCAA letter informed the Veteran of the elements required to establish service connection for his left knee disability on a secondary basis. Following these additional VCAA letters, the Veteran's left knee disability claim was readjudicated in supplemental statements of the case (SSOCs) dated in August 2004, November 2006, June 2009, January 2013, and June 2013, thereby curing any prior notice defect(s). See id. In light of the denial of his claim for service connection for a left knee disability, no disability rating or effective date can be assigned, so there can be no possibility of prejudice to him under the holding in Dingess. Regarding the duty to assist, treatment records, including service treatment records (STRs) and all identified private medical records have been obtained. In addition to obtaining relevant private treatment records, the Veteran was afforded relevant VA examinations in February 2003, April 2006, July 2006, November 2009, December 2012 and May 2013. Additionally, an independent medical opinion was obtained by the Appeals Management Center (AMC) in June 2013. Collectively, these examination reports/medical opinions are responsive to the determinative questions regarding the etiology of the Veteran's claimed left knee disability. Accordingly, VA's duty to provide an adequate VA examination has been met. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (rev'd on other grounds by Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). Moreover, the RO/AMC substantially complied with the Board's March 2013 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). The Board remanded the Veteran's claims in an effort to provide the Veteran with notice regarding the evidence and information necessary to establish service connection for his claimed left knee disability on a secondary basis, and to obtain an adequate medical opinion regarding the etiology of his claimed left knee disability, including on a secondary basis. As noted, adequate notice was provided to the Veteran, and additional medical opinions were obtained, thus satisfying the Board's remand directives. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that VA employees, including Board personnel, have two duties in conducting hearings. 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. During the Veteran's August 2007 Board hearing, the issues were adequately identified, and the VLJ and the Veteran's representatives asked specific questions directed at identifying outstanding evidence that could substantiate his left knee disability claim. He was asked about treatment and was asked questions aimed at eliciting evidence that he had requisite symptoms meeting the criteria for service connection for this claimed knee disability. Information provided at his August 2007 hearing led to the Board's remand to obtain identified private treatment records and VA examinations found to be warranted by the evidence of record. As such, the Bryant duties were met. The duty to assist has, therefore, been satisfied and there is no reasonable possibility that any further notice or assistance would be reasonably likely to assist the Veteran in substantiating his claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Further notice or assistance is, therefore, not required. II. Service Connection A. Governing Law and Regulations Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Establishing service connection requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Walker, 701 F.3d 1331. Certain chronic diseases, including arthritis (gout), may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112(a), 1131, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). When service connection for such chronic diseases is at issue, the second and third elements for service connection may be established by showing continuity of symptomatology. 38 C.F.R. § 3.303(b) (2012); see Walker, 701 F.3d 1331. Service connection may be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2012). Additionally, service connection may be granted on a secondary basis for a disability that is proximately due to or the result of another established service-connected disability. See 38 C.F.R. § 3.310(a) (2012). A claim for secondary service connection generally requires competent evidence of a causal relationship between the service-connected disability and the non-service-connected disease or injury. See Jones (Wayne L.) v. Brown, 7 Vet. App. 134 (1994). There must be competent evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Similarly, any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability, and not due to the natural progress of the nonservice-connected disability, will be service connected. 38 C.F.R. § 3.310(b) (2012); see Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the nonservice-connected disability is said to have been aggravated by the service-connected disability. See 38 C.F.R. § 3.310(b) (2012). In cases of aggravation of a nonservice-connected disability by a service-connected disability, a claimant shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.322 (2012). VA will not concede aggravation unless there is medical evidence created prior to the aggravation or current level of disability that show a baseline of the disease prior to the aggravation. 38 C.F.R. § 3.310(b) (2012). In making all determinations, the Board must fully consider the lay evidence of record. Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009). A layperson is competent to report on the onset and continuity of current 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). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v, 492 F.3d at 1376-77. The Board has a duty to assess the credibility and weight of evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. at 511. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. See 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). B. Analysis Three theories for service connection are advanced in the record. During his August 2007 Board hearing the Veteran related his current knee disability directly to his active service. He specifically testified that he suffered from knee inflammation at different times during service. The record additionally contains his contentions that he was diagnosed with gouty arthritis within approximately one year after his separation from service, thus invoking the provisions of presumptive service connection for a chronic disability under 38 C.F.R. § 3.307 and 3.309. Finally, in a February 2013 letter, the Veteran advanced a theory of entitlement to service connection for his claimed left knee disability on a secondary basis, as related to his service-connected right ankle disability. The Board notes that service connection has been in effect for a right ankle strain since January 2002. Considering first the current disability requirement for service connection for a left knee disability, the Veteran's recent May 2013 VA examination diagnosed minimal arthritic findings of the left knee. Additionally, prior VA examination reports, including the December 2012 VA examination report, diagnosed gouty arthritis. Although gout was not found during the May 2013 VA examination, it has been diagnosed during the pendency of the Veteran's appeal. See Mclain v. Nicholson, 21 Vet. App. 319, 321 (2007) (noting that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim). Accordingly, based on these diagnoses, the current disability requirement has clearly been met. See Walker, supra. Turning to the second required element for service connection on a direct basis, an in-service incurrence of a disease or injury, a review of the Veteran's STRs reveals that he sought clinical treatment for knee pain in January 1981. He reported injuring his knee as a result of playing basketball. On examination, he was noted to have mild effusion of the knee. He had apprehension with movement of the knee or palpation due to pain. He additionally had tenderness superior to the patella point. The assessment was rule out torn cartilage. During a follow-up evaluation, two days later, he was still noted to have patella apprehension. The assessment at that time was a bruise. Based on this evidence, showing that the Veteran had an in-service knee injury, the Board finds that the second required element for service connection on a direct basis has been met. Accordingly, the Board is left to consider whether there is a nexus between any current left knee disability and the Veteran's active service; or in the alternative, whether there is a nexus between a current left knee disability and his service-connected right ankle disability. Post-service VA treatment records reveal that the Veteran began receiving regular private treatment with James A. Lockwood, M.D., in May 1997. At that time, he presented to establish a new source of care. He reported having been healthy all his life and only requiring hospitalization on one occasion. He specifically denied any history of arthritis. He further reported having a clean bill of health during a prior physical examination the year before. He did not present any complaints during the consultation. During a later June 1998 clinical consultation, the Veteran complained of bilateral lower extremity swelling since the week before. He reported having no history of gout. On examination he was noted to have an edema extending from his ankle to the great toe. Tenderness was noted on manipulation of his joints. The assessment was inflammatory arthritis, possibly gout. Later, during a February 2002 clinical consultation, the Veteran was found to have gout in his feet. During a December 2002 clinical consultation, he was noted to have had a gout arthritic attack earlier in the month. Laboratory findings from early December 2002 revealed a uric acid reading of 8.9. During a later, March 2005 clinical consultation, the Veteran reported that he had not had any particular flares with gout, but that he had been having some increase in right knee pain. He related his right knee pain to his active service. He did not raise any specific contentions regarding left knee pain. Finally, during a December 2007 clinical consultation, Dr. Lockwood noted that the Veteran had documented arthritis in his ankle and knees, and noted that some of his symptoms went back to the days in the infantry. The Veteran was first afforded a VA examination in connection with his service connection claim in February 2003. The examiner indicated that the Veteran did not have a history of injury to his knees. The examiner also noted that he had not undergone any type of surgery on his knees, and that he had not experienced any episodes of dislocation o the knees. During examination, mild tenderness was noted on both knees. No swelling or ankylosis was noted. The Veteran's gait was normal and independent. His knees were noted to be stable, and anterior and posterior drawer signs were negative. The diagnosis was pain in the knees secondary to muscle strain and mild functional loss. The examiner did not provide an opinion regarding the etiology of the Veteran's muscle strain of the knee. During a later April 2006 VA examination, the VA examiner noted the Veteran's history of having been seen for left knee pain in January 1981, during service. The Veteran reported suffering an additional left knee injury while performing training when he was stationed in California in 1979. He reported a current pain level severity of eight (out of ten). He reported having flares of pain weekly, and he reported having a history of gout. Diagnostic testing of the left knee was normal. The assessment was a left knee strain. The examiner additionally noted the Veteran's gout diagnoses, but opined that these diagnoses were unrelated to his military service as gout was a metabolic disease process related to overproduction and altered excretion of uric acid. The examiner also opined that where the Veteran had a left knee bruise during service; it was at least as likely as not that his left knee bruise/contusion was related to his previous military service. The examiner's opinion, however, did not appear to extend so far as to include the Veteran's current left knee strain. Notably, he specifically observed that the Veteran did not have private records to indicate treatment for his left knee after his discharge from service. A July 2006 addendum opinion to the April 2006 VA examination was provided by the same VA examiner. Here, the examiner clearly opined that it was not at least as likely as not that the Veteran's current left knee strain was related to his left knee contusion/bruise during service. The examiner rationalized this opinion by noting that the Veteran was seen in January 1981, during service, related to a left knee injury, but that there were no additional medical records to support a finding of chronicity. The examiner noted that it appeared that the Veteran's left knee had not been evaluated during the preceding 25 years. On review of X-rays, there were no abnormalities noted on his left knee films. The examiner concluded that if the Veteran had suffered a significant knee injury, it was likely that posttraumatic degenerative changes would be evident on X-ray evaluation. A subsequent VA joints examination was conducted in November 2009. The Veteran reported being diagnosed with gout in 1986, after discharge from service. The examiner noted his complaints of moderate to severe aching type pain to his knees. He additionally reported swelling, giving out, and instability. X-rays taken of the Veteran's left knee revealed no acute fracture or dislocation. Tiny osteophytes were noted involving both tibial spines. Osteophytes were also seen along the posterior patella. A small area of osseous prominence was seen along the anterior inferior aspect of the patella on the lateral view, which could represent normal variation versus sequella from old trauma. An approximately five millimeter (mm) ovoid radiopaque density was seen in the posterior soft tissues at the level of the distal femur on the lateral view, which was of unknown etiology but could represent the fabella. A five to six millimeter round area of lucency, with sclerosis around the rim, was seen on the patellar sunrise view. This was also of unknown etiology. The impression from the X-ray report included, no acute fracture or dislocation; mild degenerative changes; and small round lucency in the anterior aspect of the left patella. Following examination of the Veteran, the examiner diagnosed gout to multiple joints, including the knees, and mild degenerative changes to the knees. The examiner provided the opinion that the Veteran's left knee condition was at least as likely as not caused by or had its onset during service. The examiner rationalized the opinion by noting that the Veteran was diagnosed with a contusion during service. No other reasons were provided for the opinion. The examiner also noted that the Veteran's gout was diagnosed after his separation from service. The Veteran was afforded a new VA examination in December 2012. The examiner noted the Veteran history of having fallen while serving in Korea, injuring his left knee. The Veteran received no other left knee treatment until approximately two to three years before the examination, when he was found to have gout. In reviewing imaging studies of the Veteran's knee, the examiner noted that degenerative or traumatic arthritis was not documented. The examiner provided the opinion that it was less likely as not that the Veteran's current left knee disability was caused by or resulted from his active service. Here, the examiner noted that the Veteran's primary disability resulted from gouty arthritis, which was diagnosed long after his separation from service. The examiner further noted that his in-service left knee injury was an acute condition which went on to spontaneous resolution. In March 2013, the Board remanded the Veteran's claim in order to obtain an etiological opinion regarding any incurrence of a left knee disability as secondary to his service-connected right ankle disability. During an April 2013 VA examination of his right ankle, the VA examiner noted the Veteran's in-service history of suffering a right ankle injury while playing football in June 1982, when he was diagnosed as having a strain of the calcaneofibular ligament. The examiner commented that the Veteran's STRs indicated that he presented with left knee pain in June 1981, after jumping while playing basketball. His right ankle condition which he claimed caused the left knee condition did not occur until June 1982, nearly a year after his initial in-service left knee injury. No opinion regarding the relationship between the Veteran's right ankle and his left knee was provided. The Veteran was afforded a new VA examination of his right ankle and left knee in May 2013. The examiner noted the Veteran's contention of developing left knee pain sometime after injuring his right ankle. He reported only receiving medication on occasion for his pain. The examiner noted in the report that diagnostic testing did not reveal any degenerative or traumatic arthritis. Based on X-rays and information of record, the examiner diagnosed minimal arthritic left knee findings, consistent with the usual aging process. The examiner opined that it was not at least as likely as not that the Veteran's present left knee condition was caused by or resulted from his current service-connected right ankle disability. An additional VA medical opinion with respect to the Veteran's left knee disability was obtained in June 2013. The examiner's report included the results of X-rays taken in May 2013. Findings noted that the bony alignment was satisfactory. There was no fracture, subluxation, erosion, joint effusion, and/or joint space narrowing. Tiny patellar spurs were seen, but no soft tissue calcification was noted. The impression was no significant abnormality. The VA physician then provided the opinion that the Veteran's left knee condition, with no currently diagnosed left knee disorder, was less likely than not proximately due to or the result of or aggravated by his service-connected right ankle condition. The physician indicated that he was in agreement with the prior examiner in that the Veteran had minimal arthritic findings consistent with the aging process of a male his age. The VA physician further indicated that he was unable to find any medical literature to create a nexus between the Veteran's left knee condition and his service. He noted that there was an absence of scientifically based medical literature supporting a proximate causal relationship or aggravation for knee disorders by ankle disorders, ipsilateral or contralateral. The physician further noted that degenerative joint disease (osteoarthritis) was a disease of aging and mechanical stresses, as described in a cited medical treatise. He also noted that the evidence for the Veteran having a current diagnosis of degenerative joint disease of the left knee is minimal with "no significant abnormality" found by X-ray. In addition to the medical evidence of record, the Veteran offered testimony during his August 2007 Board hearing. He testified that he began receiving treatment from Dr. Lockwood within approximately one year after his separation from service. He indicated his belief that orthopedic problems, including of his left knee, were incurred at least in part as a result of carrying heavy military equipment and steady walking for six to seven hours per day. He reported that his knees would swell up at different times. He further reported that he currently experienced swelling in his knees approximately every month. He also noted that he was diagnosed with gouty arthritis by Dr. Lockwood, and that his gout also affected his knees. Based on a thorough review of all evidence of record, the Board cannot make a finding that the Veteran's claimed left knee disability was incurred during or as a result of his active service, to include as secondary to his service-connected right ankle disability. In this regard, the Board observes that there is no competent medical evidence of record etiologically relating a current left knee disability to the Veteran's service, either on a direct basis, or as secondarily related to his service-connected right ankle disability. Notably, although the April 2006 VA examiner indicated that the Veteran had a left knee bruise during service, he did not clearly opine that the Veteran had a current disability that was at least as likely as not etiologically related to service. In a subsequent July 2006 opinion, the examiner clearly indicated that his opinion was that the Veteran's current left knee strain was not at least as likely as not related to service, and he rationalized this opinion by noting an absence of chronicity, and an absence of noted abnormalities on the Veteran's current X-rays. Namely, the examiner noted that posttraumatic changes, which would likely indicate ongoing disability associated with his in-service injury, were not found at that time. The Board finds that this opinion is well-informed, well-reasoned, and fully articulated, and accordingly, the Board affords this opinion significant probative value. Additionally, although the November 2009 VA examiner opined that the Veteran's left knee condition was at least as likely as not related to service, the examiner only appeared to indicate that the opinion was based on the Veteran's noted in-service contusion of the left knee. No clear relationship between the current condition and the contusion was indicated. In contrast to this opinion, the December 2012 VA examiner's opinion more clearly indicated that the Veteran's left knee injury was an acute condition and ended in spontaneous resolution. The examiner further indicated that the Veteran's current disability was gout, which was diagnosed long after service. Based on these clear findings, the Board finds that the December 2012 VA examiner's opinion is of greater probative value than the November 2009 VA examiner's opinion with respect to a claimed direct relationship between the Veteran's claimed left knee disability and his service. Moreover, the December 2012 VA examiner's opinion is greatly bolstered by the highly probative June 2006 VA examiner's opinion. Similarly, the VA opinions of record have clearly dissociated the Veteran's current left knee condition from his service-connected right ankle condition. The June 2013 VA physician's opinion clearly noted that the Veteran's left knee condition was not caused or aggravated by his service-connected right ankle disability. The physician again noted that the Veteran had minimal arthritic findings and that such findings were consistent with the aging process, not with secondary impairment caused by a right ankle disability. He additionally noted that medical literature did not support such a causal relationship or aggravation of knee disorders by ankle disorder. This well-informed, well-reasoned, and fully articulated opinion is also of significant probative value with respect to the Veteran's secondary service connection claim. Moreover, the opinion clearly provided an alternate etiology for the minimal arthritic findings in the Veteran's left knee, namely the Veteran's age. The April 2006, November 2009, and December 2012 VA examiner opinions further clearly dissociated the Veteran's gout from his service by noting that gout was a distinct disability (metabolic disease process related to overproduction and altered excretion of uric acid), and not related to any in-service injury; and in the Veteran's case, was diagnosed many years after his separation from service. Although the Veteran has expressed his opinion that his left knee disability was either caused by an in-service knee injury, or was related to his service-connected right ankle disability, he unfortunately lacks the requisite medical expertise. Therefore, his opinions do not constitute competent evidence regarding the etiology of his claimed left knee disability. See Jandreau v, 492 F.3d at 1376-77. The evidence of record additionally does not support a finding that the Veteran's gout or any other type of knee arthritis developed within the one-year period following his separation from service. Although the Veteran testified during his August 2007 hearing that he began receiving treatment from Dr. Lockwood within one year after his separation from service, and although he reported during his November 2009 VA joints examination that he was diagnosed with gout in approximately 1986, a review of his private treatment records from Dr. Lockwood unequivocally shows that he began receiving private treatment from Dr. Lockwood in May 1997, not in 1985 or 1986. Furthermore, a December 2007 letter from Dr. Lockwood confirms that he began treating the Veteran in May 1997, not before. A thorough review of the Veteran's private treatment records additionally reveals that he was first suspected of having gout in June 1998; at which time he was assessed with inflammatory arthritis, possibly gout. These contemporaneous treatment records are far more probative than the Veteran's more recent and unreliable recollections regarding his treatment history. Thus, the provisions of 38 C.F.R. § 3.307 and 3.309 are clearly not applicable in this case. Finally, the evidence of record has established that the Veteran's gout developed long after his separation from service. Similarly, his minimal degenerative findings were not found until many years after his service. Although Dr. Lockwood has indicated that some of the Veteran's symptoms extended back to service, there is no clear evidence of complaints of knee pain or knee treatment until, at the earliest, approximately 1998, when the Veteran was noted to possibly have gout. Moreover, the Veteran's contentions that he reported for treatment within a year after his service have been soundly refuted by the evidence of record. Accordingly, there is no competent evidence to support a finding of continuity of symptomatology in this appeal. There is similarly no evidence of chronicity of knee symptoms during the Veteran's service. Thus, the provisions of 38 C.F.R. § 3.303(b) are inapplicable. In sum, there is no competent evidence linking any current left knee disability to the Veteran's active service, by means of his in-service knee contusion, of his service-connected right ankle disability, or otherwise. Absent such competent evidence, the Board finds that the preponderance of the evidence is against his service connection claim. Reasonable doubt does not arise and the claim for service connection for a left knee disability, to include as secondary to a service-connected right ankle disability, must be denied. 38 U.S.C.A. § 5107(b) (West 2002). ORDER Entitlement to service connection for a left knee disability is denied. _________________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs