Citation Nr: 1328258 Decision Date: 09/04/13 Archive Date: 09/10/13 DOCKET NO. 08-15 541 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for residuals of total right knee replacement. 2. Entitlement to service connection for residuals of total left knee replacement, to include as secondary to a right knee disability. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from March 1971 to December 1972. These matters come before the Board of Veterans' Appeals (Board) from July 2005 and April 2006 rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO) in Atlanta, Georgia. In October 2011, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These matters were previously before the Board in July 2012 and were remanded for further development. They have now returned for further appellate consideration. The Board finds that the RO substantially complied with the mandates of the remand and will proceed to adjudicate the appeal. FINDINGS OF FACT 1. The earliest clinical evidence of a right knee disability is in 1986, more than thirteen years after separation from service. 2. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran's right knee disability is causally related to, or aggravated by, service, 3. The probative evidence of record is against a finding that the Veteran's right knee disability is causally related to, or aggravated by, service. 4. The earliest clinical evidence of a left knee disability is in 2004, more than thirty years after separation from service. 5. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran's left knee disability is causally related to, or aggravated by, active service, or a service-connected disability. 6. The probative evidence of record is against a finding that the Veteran's left knee disability is causally related to, or aggravated by, service, or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of total right knee replacement have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2012). 2. The criteria for service connection for residuals of total left knee replacement, to include as secondary to a service-connected disability, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided in May 2005, October 2005, and August 2012. VA has a duty to assist the appellant in the development of the claims. The claims file includes service treatment records (STRs), medical records, Social Security Administration (SSA) records, and the statements of the Veteran and others in support of the claims. The claims file includes a June 2013 National Personnel Record Center (NPRC) response to a request for records. It reflects that a search of unit records for the Veteran and his alleged knee injury was negative for any remarks. A July 2013 VA memorandum on a formal finding on unavailability of morning reports is also associated with the claims file. The Veteran has asserted that he sought treatment for his right knee post-service in approximately 1978 or 1979 at the Augusta VA, and that he had surgery in the early 1980s, and then another surgery two years later. The claims file includes VA clinical records which reflect surgery at the Augusta, Georgia VA facility in November 1986 and again in December 1988. The records do not reflect earlier surgeries or treatment. In August 2012, the Veteran was requested to provide the dates of his treatment at a VA facility. He did not respond to the request. The duty to assist is not a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board finds, based on the record as a whole, that a further remand would serve no useful purpose. At his October 2011 Board hearing, the Veteran stated that his doctor stated that his left knee "went bad" because he favored it for so long". The Veteran stated that he could see about having his doctor write such a statement. (See Board hearing transcript page 6.) It has now been almost two years and the Veteran has not provided VA with any such evidence. As noted above, the duty to assist is not a one-way street. Wood v. Derwinski, Id. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the August 2012 VA opinion is adequate. The opinion is predicated on consideration of the Veteran's disabilities, his symptoms, and his medical history. Adequate rationale has been provided. The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. 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 attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of 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. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease," whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Service Connection on a secondary basis Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). During the course of this appeal, VA amended 38 C.F.R. § 3.310 effective October 10, 2006). See 71 Fed. Reg. 52,744 -47 (Sept. 7, 2006). The amended 38 C.F.R. § 3.310 (b) institutes additional evidentiary requirements and hurdles that must be satisfied before aggravation may be conceded and service connection granted. To whatever extent the revised regulation may be more restrictive than the previous one, the Board will afford the Veteran review under both the old and new versions. See VAOPGCPREC 7-2003 (Nov. 19, 2003). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence pertinent to the claims on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Total Right Knee Replacement The Veteran avers that he had a total right knee replacement as a result of active service. An essential element of a claim for service connection is evidence of a current disability. 2004 VA clinical records reflect that the Veteran had a total right knee replacement. Thus, this element has been met. A second element of a claim for service connection is medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease. The Veteran asserts that he injured his right knee on at least two separate occasions in service while in Vietnam. (The records reflect that the Veteran was in Vietnam from August 12, 1971 through June 19, 1972.) First, he contends that he cut his right knee with a machete. He reports that approximately a week later, it had swollen so big that he could not walk on it. He further reports that he was transported by helicopter to a hospital in Da Nang, where his knee was shaved and cleaned, and he was placed on crutches. He stated that he was in the "rear" for approximately a week or two before being returned to his unit. The STRs are negative for any such incident. The only incident which reflects treatment for the leg is a May 1972 STR which reflects that the Veteran had a boil on the right leg and that the Veteran was to have "heat treatment". (The Veteran also had a boil on the chin in February 1972.) It is negative for any crutches or swelling. The Veteran asserts that it was not a boil, as noted in the STRs, but jungle rot in his cut. The Veteran asserts that he injured his right knee the second time when he jumped from a helicopter during combat. The Veteran's DD214 reflects that he had combat in Vietnam (i.e. combat infantryman badge). In the case of a Veteran who engaged in combat with the enemy in a period of war, lay evidence of in-service incurrence or aggravation of a disease or injury shall be accepted if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the lack of official record of such incurrence or aggravation. 38 U.S.C.A. § 1154(b); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996). The phrase "engaged in combat with the enemy" requires that the veteran have personally participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. VAOPGCPREC 12-99 (October 18, 1999); Gaines v. West, 11 Vet. App. 353 (1998). A February 2005 VA record reflects that the Veteran reported that he had cut his knee with a machete by accident in Vietnam (as discussed above), and that he had cut his knee once on elephant grass, "both times resulting in infection and time on crutches, but [the Veteran] states there are no records of this." In his April 2005 claim, the Veteran stated that he injured his right knee while walking point during combat patrol, and that his injury was treated at a nearby hospital. He asserted that his right knee was reinjured in January 1972 after he jumped from a helicopter while taking incoming fire. He stated that his knee was treated at a field hospital. As noted above, the Veteran served in Vietnam for ten months from August 12, 1971 to June 19, 1972. According to the STRs, the Veteran sought treatment, while in Vietnam, on five occasions. He was seen for a boil on the chin on two occasions in February 1972, a left arm injury on two occasions in April 1972, and, as noted above, a boil on the right leg in May 1972. When the combat presumption has been triggered, a medical examiner cannot rely on the absence of medical records corroborating that injury to conclude that there is no relationship between current disability and his military service. Dalton v. Nicholson, 21 Vet. App. 23, 40 (2007). (As discussed in further detail below, the 2012 VA clinician applied the "combat presumption" when providing an opinion with regard to the Veteran's claims and considered the Veteran's assertion as to knee injuries in service.) The Veteran's September 1972 report of medication examination for separation purposes reflects that his lower extremities were normal upon clinical examination. The Veteran reported that he was in "good health". Thus, the Board finds that any knee injury in service was acute and transitory as his knees were normal upon clinical examination upon separation. The Veteran separated from service in December 1972. On November 29, 1972, he filed a claim for entitlement to service connection for a sinus disability. The Veteran did not file a claim for a knee disability at that time. The Board finds that if the Veteran had been experiencing knee complaints at that time, it would have been reasonable for him to have filed a claim for entitlement to service connection for a knee disability when he filed a claim for his sinuses; he did not. The Veteran stated, in his May 2008 VA Form 9, that "soon after leaving army my knees started swelling again." The Board finds that any contention that the Veteran's knees began to swell within two months after separation from service is less than credible, given the record as a whole. A February 1973 VA general medical examination report is of record. It reflects that the Veteran had a scar on the "anterior right knee and one on anterior left knee where boils were lanced, one in childhood and two in the service, and these healed without residuals". It was noted that the scar on the anterior right knee is slightly tender on palpation but there was no injury to the bones of the knee." It was further noted that all of the extremities "function to the full range of motion, and there is no tenderness in any of the joints otherwise. The Veteran can stand on his toes and on his heels and can squat normally. Straight leg raising test is negative on both legs." The report reflects that he had returned to his job in body repair work after service and that the Veteran had not lost any time from work and had not consulted a physician since he left service. The record is entirely negative for a swelling of the knees. In addition, the report does not reflect any residuals of machete wounds, jumping injuries, or any prior knee injuries other than boils. The 1973 report also notes that the Veteran had no serious injuries in his past history and no complaints other than with regard to his sinuses. It was noted that his only minor injuries in the past history were a scar from a minor injury over the right eyebrow, a scar on the left forearm from a cyst removal in Vietnam, a scar under the chin, one scar on each knee from lanced boils, and a sebaceous cyst which had developed since service. Again, the Board finds that if the Veteran had chronic pain or swelling, or intermittent pain or swelling of his knees since service in Vietnam, it would have been reasonable for him to have reported it, and for it to have been noted, in February 1973 when he was being examined. Although the examination was in relation to a claim for entitlement to service connection for a sinus disability, the record is clear that the Veteran's lower extremities were examined by the clinician. The provisions of 38 U.S.C.A. § 1154(b) do not establish a presumption of service connection, but ease the combat Veteran's burden of demonstrating the occurrence of some in-service incident to which the current disability may be connected. See Caluza v. Brown, 7 Vet. App. 498 (1995). That is, the statute provides a basis for determining whether a particular injury was incurred in service, but not a basis to link the injury etiologically to the current condition. Dalton v. Nicholson, 21 Vet. App. 23, 36-37 (2007); Cohen v. Brown, 10 Vet. App. 128, 138 (1997); Libertine v. Brown, 9 Vet. App. 521, 523-24 (1996). In-service incurrence by way of the combat presumption may also be rebutted by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b). That is, if the lay or other evidence of service incurrence is satisfactory and consistent with the Veteran's combat service, the Veteran prevails unless this evidence is rebutted by clear and convincing evidence that the disease or injury was not incurred or aggravated in service or during an applicable presumptive period. See 38 U.S.C.A. § 1154(b); Caluza v. Brown, 7 Vet. App. 498 (1995); Arms v. West, 12 Vet. App. 188 (1999). However, the combat presumption does not extend to the Veteran's statement that he would have had a knee disability upon separation; it merely allows for the presumption that an incident occurred in combat. The earliest post service evidence of a right knee disability is in 1986, more than 13 years after separation from service. A 1986 record reflects that, in November 1986, the Veteran had arthroscopy with removal of plica on the right knee. The diagnosis was "medial compartment plica". A December 1988 VA clinical record reflects that the Veteran had had surgery for a medial meniscal tear of the right knee, posterior horn; osteochondral defect, medial aspect of the medial femoral condyle. (The 1986 records reflect a "very small radial tear was noted in the medial meniscus".) The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Notably,the record reflects that the Veteran was employed in manual labor (i.e. automotive body repair) from at least 1979. The claims file includes a November 2005 statement from the Veteran's sister, B.B. She stated that she remembered getting a letter from the Veteran while he was in Vietnam that he had injured his knee from jumping out of a helicopter. The claims file also includes a June 2005 statement from J.H., in which he stated that he served in Vietnam from August 1971 to April 1972. He stated that on "one occasion [the Veteran] injured his knees with a machete while cutting it on patrol. On another occasion [the Veteran] injured his knees after jumping from a helicopter to go on a mission." The claims file also includes a November 2007 statement from R.B. He states that he was in Vietnam with the Veteran in 1971 and 1972. He further stated: We were transported to the field using helicopters. Many times the helicopters could not or would not land for us to unload so we would have to jump to the ground. Sometimes this was 10 to 20 feet. The ruck sacks that we carried on our backs weighed about 75 pounds. This weight plus our weapons plus the jump sometimes caused injuries. I do remember [the Veteran] severely injuring his right knee during one of these jumps. His knee later swelled to about twice its normal size. I have no doubt that this injury caused or at least contributed to his pain and knee problems over his lifetime. A third requirement for service connection is competent credible evidence of a nexus between the current disability and the in-service disease or injury. The Board finds, for the reasons noted below, that this third requirement for service connection has not been met. The claims file includes an August 2012 VA clinical opinion. The clinician assumed that both the Veteran's machete injury and his jumping out of a helicopter are valid under the "combat presumption"; however, he concluded that they were not the cause of the Veteran's current right knee disability. The clinician stated, in pertinent part, as follows: Concerning the machete injury, the specifics are unclear, but given the presumed mechanism of injury (blow to knee with a blade) a laceration type injury and/or soft tissue contusion are the most logical types. This is supported by the development of swelling and "jungle rot" which are presumed to represent inflammation and possibly superinfection of the injured tissue. This was apparently effectively treated by cleansing and rest. Such a condition would be less likely than not to have resulted in the development of DJD of the knee since there is no information to suggest actual knee joint involvement. This acute injury apparently healed and, thus, is less likely than not to have resulted in the development of chronic [right] knee joint DJD. Considering the helicopter jump history and effect on the [right] knee, there is conflicting evidence. Veteran history with corroboration by fellow soldiers provides mechanism of acute non-severe injury of to [sic] [right] knee in 1971/2. In 1986 medical plica excision then in 1988 medial menisectomy occurred (plica are fetal synovial tissue that exist vestigially in adults as synovial folds; these folds can be prominent and are subject to irritation, with the medial location the most common.) Given the duration between 1971/2 and 1986 along with the absence of knee issues at discharge (on history and exam) it is less likely than not that a link between service and subsequent chronic [right] knee condition exists. The Board finds that the December 1972 and February 1973 clinical records, which were made contemporaneous to separation and shortly thereafter, are thus, more probative as to the Veteran's right knee status at that time than the statements made decades later for compensation purposes. See Cartright v. Derwinski, 2 Vet. App.24, 25 (1991) (finding that, while the Board may not ignore a Veteran's testimony simply because he or she is an interested party and stands to gain monetary benefits, personal interest may affect the credibility of the evidence); see also Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the testimony). While the Veteran may have injured his right knee in Vietnam, such injuries were acute and transitory as evidenced by the clinical findings in December 1972, which was six months after service in Vietnam, and at least eight months after his injuries, as noted by the buddy statement. (The Veteran's one buddy statement reflects that the buddy served in Vietnam until April 1972; thus, if he had witnessed the Veteran's knee injuries, such injuries would have to have occurred prior to the end of April 1972.) Moreover, the Veteran's right knee joint was normal upon clinical examination in February 1973, eight months after his service in Vietnam, and at least 10 months after his injuries noted by his buddy. The Board has considered the lay statements of record. Notably, the clinician who provided an opinion in 2012 considered that the Veteran injured his right knee in service with a machete and by jumping from a helicopter. The Veteran, and his family and friends, may sincerely believe that he has a right knee disability due to service. The Veteran is competent to relate his symptoms, such as pain. However, the Veteran, and the Veteran's friends and family, have not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation of degenerative joint disease. Moreover, the opinion of the clinician, who has medical education, training, and experience, is more probative than that of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011). See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In sum, the Board finds that any injury in service was acute and transitory, that the Veteran's right knee was normal upon separation and normal two months after separation, and that the clinical evidence does not support a causal relationship between his current right knee disability and active service. The Board appreciates the Veteran's honorable service, to include his combat in Vietnam; however, the competent credible evidence of record is against a finding that the Veteran has a right knee disability causally related to active service. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2012), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Total Left Knee Replacement The Board will not repeat all of the facts noted above, but has considered them when they are pertinent to the Veteran's left knee. The Veteran's STRs are negative for any complaints of, or treatment for, a left knee disability. The STRs reflect that the Veteran sought treatment, while in Vietnam, on five occasions. He was seen for a boil on the chin on two occasions in February 1972, a left arm injury on two occasions in April 1972, and, as noted above, a boil on the right leg in May 1972. The Veteran's September 1972 report of medication examination for separation purposes reflects that his lower extremities were normal upon clinical examination. The Veteran reported that he was in "good health". The Veteran separated from service in December 1972. As noted above, on November 29, 1972, he filed a claim for entitlement to service connection for a sinus disability. The Veteran did not file a claim for a knee disability at that time. The Board finds that if the Veteran had been experiencing knee complaints at that time, it would have been reasonable for him to have filed a claim for it when he filed a claim for his sinuses; he did not. Also as noted above, a February 1973 VA examination report, two months after separation from service, reflects that the Veteran had a scar on the on anterior left knee due to a boil lancing which had healed without residuals. It was further noted that all of the extremities "function to the full range of motion, and there is no tenderness in any of the joints otherwise. The Veteran can stand on his toes and on his heels and can squat normally. Straight leg raising test is negative on both legs." The report reflects that he had returned to his job in body repair work after service and that he had not lost any time from work and had not consulted a physician since he left service. The record is entirely negative for a swelling of the knees. In addition, the report does not reflect any residuals from jumping injuries or any prior leg injuries other than boils. In sum, there is no clinical evidence of a left knee joint disability upon separation from service, or two months after separation from service. The earliest clinical evidence of a left knee disability is in 2004, more than 30 years after separation from service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). A September 2004 VA clinical record reflects that the Veteran reported that his left knee pain has been worsening over the last 20 year, or since approximately 1984. A January 2005 VA clinical record reflects that the Veteran had left knee surgery (total left knee replacement) in September 2004. A November 2010 VA clinical record reflects that the Veteran reported that he hurt his left knee from stepping in a hole and he has been having pain from that injury. The report does not reflect that the Veteran contended that the incident happened in service. In addition, in August 2005, the Veteran stated it was his right knee that was injured in service. At his October 2011 Board hearing, the Veteran contended that his left knee was secondary to his right knee disability. The claims file includes an August 2012 VA clinical opinion. The clinician opined, in pertinent part, as follows: Since both knees underwent replacement surgery in the same year, it is most logical to conclude that both knees were experiencing degenerative processes simultaneously . . . which disfavors the concept of [right] knee causing [left] knee problems. If this were the case one would expect to see a greater temporal separation between [right] and [left] knee replacements. Hence, it is less likely than not that [right] knee condition would have played a role in the [left] knee condition. Again, too, the lack of knee issues at discharge supports this conclusion. While the clinician did not specifically state that the left knee injury was less likely as not due to jumping from helicopters, a review of his rationale for the right knee is consistent with such a finding. (i.e. given the duration between service and the earliest clinical evidence of a disability, along with the absence of knee issues at discharge (on history and exam) it is less likely than not that a link between service and subsequent chronic knee condition exists.) The Veteran is service connected for posttraumatic stress disorder, tinnitus, and bilateral hearing loss. There is no competent credible evidence of record that he has a left knee disability causally related to active service, or to a service connected disability. In addition, even if the Veteran's left leg disability were secondary to a right knee disability, the Veteran is not service connected for his right knee; thus, a disability secondary to it does not warranted service connection. The Veteran may sincerely believe that he has a left knee disability due to service or a service-connected disability. He is competent to relate his symptoms, such as pain. However, the Veteran, and the Veteran's friends and family, have not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation of degenerative joint disease. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011). See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Moreover, the opinion of the clinician, who has the experience and training, is more probative. In sum, the Board finds that any injury in service was acute and transitory, that the Veteran's left knee was normal upon separation and normal two months after separation, and that the clinical evidence does not support a causal relationship between his current left knee disability and active service, or a service connected disability, to include aggravation. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2012), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for residuals of total right knee replacement is denied. Entitlement to service connection for residuals of total left knee replacement, to include as secondary to a right knee disability is denied. ____________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs