Citation Nr: 1328606 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 09-46 795A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a right knee disorder and, if so, whether service connection is warranted. 2. Entitlement to service connection for a left knee disorder, to include as secondary to a right knee disorder. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from June 1969 to April 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In January 2009, the Veteran expressed timely disagreement with the November 2008 rating decision and a statement of the case was issued in June 2009. In December 2009, the Veteran submitted a statement from his physician and renewed his claims for service connection for both knees. Although the RO initially interpreted the statement as a petition to reopen his claims and issued a rating decision in March 2010 denying such claims, in June 2010 the RO accepted the statement as a substantive appeal in lieu of a VA Form 9 and conducted further development. In a July 2010 supplemental statement of the case, the RO essentially reopened the claim for the right knee, but denied service connection for both knees on the merits. Therefore, in light of the procedural history of the claims, the Board finds that such are on appeal from the December 2008 rating decision and, as such, the March 2010 rating decision is rendered moot. The December 2008 rating decision also denied service connection for bilateral hearing loss and tinnitus, and the Veteran entered a timely notice of disagreement as to such denials. Thereafter, in a June 2009 rating decision, service connection for bilateral hearing loss was granted, thus resolving such issue. Furthermore, after the issuance of the statement of the case in June 2009, the Veteran did not enter a timely substantive appeal with respect to the issue of entitlement to service connection for tinnitus. Rather, in the statement accepted in lieu of VA Form 9, the Veteran only referenced his bilateral knees. Therefore, such issue has not been perfected for appeal and, consequently, is not properly before the Board. The Board observes that additional evidence consisting of private treatment records was associated with the claims file subsequent to the issuance of the July 2010 supplemental statement of the case. In this regard, such include June 2010 and August 2010 records showing a notation that the Veteran's past medical history included a diagnosis of degenerative joint disease of the bilateral knees. As such evidence is duplicative of the evidence previously of record, which reflects such a diagnosis, a remand for the agency of original jurisdiction (AOJ) to consider such evidence is not necessary. 38 C.F.R. § 20.1304(c) (2012). In addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal with the exception of the Veteran's representative's August 2013 Appellant's Brief. FINDINGS OF FACT 1. In a final decision dated in July 1972 and issued in August 1972, the RO denied the Veteran's claim of entitlement to service connection for residuals of right knee pain. 2. Evidence added to the record since the final August 1972 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for a right knee disorder. 3. A right knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service, and arthritis did not manifest within one year of the Veteran's discharge from service. 4. A left knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service, arthritis did not manifest within one year of the Veteran's discharge from service, and it is not shown to be caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The August 1972 decision that denied service connection for residuals of right knee pain is final. 38 U.S.C. § 4005(c) (1970) [38 U.S.C.A. § 7105(c) (West 2002)]; 38 C.F.R. §§ 3.104, 19.118, 19.153 (1972) [38 C.F.R. §§ 3.104, 20.302, 20.1103 (2012)]. 2. New and material evidence has been received to reopen the claim of entitlement to service connection for a right knee disorder. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). 3. The criteria for service connection for a right knee disorder are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 4. The criteria for service connection for a left knee disorder are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. Relevant to the Veteran's application to reopen his claim of entitlement to service connection for a right knee disorder, as the Board's decision to reopen such claim is completely favorable, no further action is required to comply with the VCAA in this regard. Pertinent to the merits of the Veteran's service connection claims, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a July 2008 letter, sent prior to the initial unfavorable decision issued in December 2008, advised the Veteran of the evidence and information necessary to substantiate his service connection claims on a direct and presumptive basis as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. The Board observes that the Veteran has claimed, in part, that his left knee disorder is caused or aggravated by his right knee disorder. While he was not provided with proper VCAA notice pertaining to the secondary aspect of his claim, the Board finds that no prejudice to him results from such deficient notice as his claim for service connection for a right knee disorder is denied herein. Therefore, his claim for service connection for a left knee disorder as secondary to such disability must be denied as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (2007); Sabonis v. Brown, 6 Vet. App. 426 (1994). Relevant to the duty to assist, the Veteran's service treatment records as well as post-service private and VA treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran was also afforded a VA examination in July 2010. As relevant to his claim for service connection for a right knee disorder, the Board finds that the VA examination and accompanying opinion is adequate to decide the issue as it is predicated on an interview with the Veteran; a review of the record, to include his service treatment records; and a physical examination with diagnostic testing. The opinion proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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"). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the issue of entitlement to service connection for a right knee disorder has been met. The Board observes that the July 2010 VA examiner did not offer an opinion regarding the etiology of the Veteran's left knee disorder, to include whether such is secondary to his right knee disorder. However, the Board finds that such is not necessary in the instant case. Specifically, as will be discussed below, there is no evidence that the Veteran injured his left knee during service and no indication that such is otherwise related to service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this regard, the Veteran has only claimed right knee symptoms during service and has contended that his left knee disorder is secondary to his right knee disorder. Despite his private physician's June 2010 statement that the Veteran's knee problems are likely to have been caused by his military injury, the Veteran has not alleged an in-service left knee injury or a continuity of left knee symptomatology since service. Moreover, as service connection for a right knee disorder is denied herein, an opinion regarding whether the Veteran has a left knee disorder secondary to such is not necessary. The Court has held that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Additionally, a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide the Veteran's claim of entitlement to service connection for a left knee disorder. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis, supra, at 430 (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis The Veteran served as a U.S. Army cook with service in the Republic of Vietnam from May 1970 to April 1971. In a November 2009 statement, he contended that he injured his right knee in service while stationed at Fort Jackson, South Carolina, and that his left knee disorder was caused by overcompensation for the right knee. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, to including arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters, supra. The Board must weigh any competent lay evidence and to make a credibility determination as to whether it supports a finding of service incurrence; or, if applicable, continuity of symptomatology; or both, sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Layno, supra. The credibility of lay evidence may not be refuted solely by the absence of corroborating contemporaneous medical evidence, but it is a factor. Davidson v. Shinseki, 581 F.3d at 1313, 1316 (Fed.Cir. 2009). Other credibility factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). 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. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Reopening a Final Decision In a July 1972 rating decision, the RO denied service connection for residuals of right knee pain. In this regard, after a review of the Veteran's service treatment records, including a January 1970 encounter for treatment of right knee pain, the results of an April 1971 discharge physical examination, and VA hospital records of unrelated treatment in January 1972, the RO concluded that the Veteran did not have a residual right knee disability. Rating actions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of an RO decision to initiate an appeal by filing a notice of disagreement with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C.A. § 7105(b) and (c); 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.202, and 20.302(a). In August 1972, the Veteran was advised of the decision and his appellate rights. However, no further communication regarding his claim of entitlement to service connection for a right knee disorder was received until June 2008, when VA received his application to reopen such claim. Therefore, the January 1971rating decision is final. 38 U.S.C. § 4005(c) (1970) [38 U.S.C.A. § 7105(c) (West 2002)]; 38 C.F.R. §§ 3.104, 19.118, 19.153 (1972) [38 C.F.R. §§ 3.104, 20.302, 20.1103 (2012)]. In this regard, the Board has considered the applicability of 38 C.F.R. § 3.156(b), which provides that, when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. However, in the instant case, such regulation is inapplicable as no evidence pertaining to the Veteran's claim for service connection for a right knee disorder was received prior to the expiration of the appeal period stemming from the August 1972 rating decision. See also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Roebuck v. Nicholson, 20 Vet. App. 307, 316 (2006); Muehl v. West, 13 Vet. App. 159, 161-62 (1999). The RO received the Veteran's claim for a right knee disorder in June 2008. The Veteran did not describe his symptoms or comment on the origin of the disorder, but in October 2008, the Veteran submitted a record of treatment by a private physician in 2002 for a right knee meniscal tear. The physician noted the Veteran's report of experiencing right knee symptoms for "many months" but did not mention injuries or events in service. The RO construed the claim as an application to reopen his claim for service connection for a right knee disorder. In a statement in November 2009, the Veteran associated his right knee disorder with an injury incurred while stationed in Fort Jackson. In this regard, the Board notes that a change in diagnosis or specificity of the claim must be carefully considered in determining the etiology of a potentially service- connected condition and whether the new diagnosis is a progression of the prior diagnosis, correction of an error in diagnosis, or development of a new and separate condition. Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008). In this case, the Veteran referred to the same injury in service in January 1970 at Fort Jackson as was previously considered. Since the current diagnosis is that of right knee damage based on the same event as the time the case was last decided on the merits, new and material evidence is necessary to reopen the claim. Id. Generally, a claim which has been denied in an unappealed Board decision or an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Since the August 1972 decision, the RO received the following evidence: a July 2002 outpatient treatment record from a private orthopedic physician; VA outpatient treatment records dated from September to October 2008; November 2009 and June 2010 statements from a private physician; record of a VA examination in June 2010; and a statement from the Veteran in November 2009. The evidence received since the August 1972 rating decision is new because it had not been previously considered. The Veteran's November 2009 statement is not material because it is duplicative of his claim in 1972 with no additional information regarding a contended injury in service. All medical evidence is material because it refers to the existence of a right knee disability, the reason for the previous denial. Moreover, in June 2010, the Veteran's private physician stated that he felt that the Veteran's knee problems are likely to have been caused by his military injury. Consequently, since the August 1972 rating decision, evidence demonstrating a current right knee disability and an indication that such is related to the Veteran's military service has been received. Therefore, as new and material evidence has been received, and to this extent only, the Board reopens the claim and will address service connection on the merits. Reopening the Veteran's claim for service connection for a right knee disorder does not end the Board's inquiry; rather, consideration of the claim on the merits is now required. As the RO has already considered the issue of entitlement to service connection on a de novo basis in a July 2010 supplemental statement of the case, and as the Veteran has had an opportunity to address the merits of his claim in written statements, the Board may proceed with a final adjudication of the merits of the claim because there is no prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384, 393 (1993). Service Connection for Right and Left Knee Disorders Service treatment records showed that the Veteran sought treatment at a military clinic at Fort Jackson in January 1970 for pain on the lateral aspect of the right knee. A clinician noted no swelling or erythema, and there was no mention of a traumatic injury. X-rays were negative. The clinician provided an elastic wrap. There was no follow-up care, and the Veteran completed a tour of duty in Vietnam from May 1970 to April 1971. Several treatment encounters during the tour of duty are silent for any knee symptoms. In an April 1971 discharge physical examination, the Veteran did not report knee symptoms, and the physician noted no abnormalities of the lower extremities. In July 2002, a private orthopedic physician noted the Veteran's report of bilateral knee pain, right worse than left, for about three years with sharp pain on the right that he had experienced for many months. The Veteran reported current pain, swelling, stiffness, and popping on motion. On examination, the left knee displayed a varus deformity and crepitation but no instability. The right knee displayed pain on full extension with a positive McMurray test but also no instability. X-rays of the right knee showed near bone on bone changes; the left knee was normal. The physician diagnosed a right knee medial meniscal tear and left knee degenerative arthritis. There were no reports by the Veteran of any injuries or relevant events in service, and the physician did not comment on the etiology of the knee disorders or any relationship between the two knees. The physician prescribed conservative treatment with medication and, if unsuccessful, injections or arthroscopic surgery to repair the meniscal tear. In October 2008, the Veteran sought the start of primary care treatment at a VA clinic. He provided a copy of the 2002 private orthopedic examination and acknowledged that he had never received follow-up care or surgery. He reported gradual increase in pain despite medication and now walked with a limp. A VA physician's assistant (PA) did not record the results of a clinical examination of the knees but obtained concurrent X-rays that showed suprapatellar joint space effusion and tricompartment degenerative arthritis of both knees, slightly more advanced on the left knee. There was no indication of a right knee meniscal tear or other acute abnormalities. The PA diagnosed bilateral knee pain and prescribed knee braces. In November 2009, the same private orthopedic physician from 2002 noted that he examined the Veteran for symptoms of bilateral knee pain and diagnosed severe degenerative joint disease on the left and moderate degenerative joint disease on the right. He noted, "I feel that his [right] knee arthritis was traumatic and his [left] knee condition was aggravated by the increased weight bearing place on it. It is noted that he has no history of injury to the left knee." At the bottom of the statement, the Veteran noted that he injured his right knee at Fort Jackson and that his left knee disorder was caused by overcompensation. In June 2010, the physician added, "I feel his knee problems are likely to have been caused by his military injury - 'more likely than probable.'" In July 2010, a VA examiner noted a review of the claims file, including the January 1970 treatment in service. The examiner noted that the Veteran thereafter completed more than another year of military service with no complaints and had a normal examination at the end of service in 1971. The examiner noted that, after service, the Veteran worked in construction occupations and as a truck driver. The examiner acknowledged the treatment notes by the private physician in 2002 and by PA in 2008, noting that the VA X-rays were non-weight bearing images. The Veteran reported that he was able to walk with the use of braces on both knees but had increased pain going down stairs and mild flare-ups at the end of the day. He experienced stiffness and a limp upon rising in the morning and was not able to squat or kneel but was able to work. There was no catching, locking, giving way, or dislocations. The Veteran reported receiving injections but no surgery. On examination, the examiner noted a moderate varus deformity of both knees with palpable medial osteophytes. Range of motion was 5 to 125 degrees on the right and 5 to 105 degrees on the left with crepitus but no pain, fatigue, or incoordination on repetition. Motor function and strength was normal and all clinical knee tests were negative. Weight bearing X-rays showed significant medial compartment arthritis on the left and to a much lesser degree on the right. Following a review of the claims file, an interview with the Veteran, and physical examination, the examiner noted that the Veteran had a 1-time complaint in January 1970 with no further complaints in service. It was further observed that he served for more than one year after the January 1970 treatment and worked for more than 30 years with no complaints until 2002. The examiner stated that there was really no evidence of a chronic ongoing condition related to military service. He further noted that the left knee was much worse on examination and on X-ray than the right knee. Therefore, the examiner opined that the right knee disorder is less likely as not due to any event in service. The Board places great probative weight on the opinion of the VA examiner as he reviewed the entire record, including the specific symptoms and treatment provided in service, the absence of any symptoms or chronic disorder at discharge, the history of construction work for 30 years, and the onset of symptoms only a few years prior to the first post-service treatment in 2002. As the VA examiner offered clear conclusions with supporting data as well as a reasoned medical explanation connecting the two, the Board accords great probative weight to his opinion. See Nieves-Rodriguez, supra; Stefl, supra. In contrast, the Board places very low probative weight on the briefly stated opinion of the Veteran's private physician in 2009 and 2010 because his conclusion that the current right knee disorder was caused by an injury was not supported by the description of the symptoms presented in January 1970 and the absence of any traumatic injury. The physician did not address the Veteran's ability to continue to perform military duties for the remainder of his service without restriction, did not explain the late onset of symptoms, or discuss the impact of decades of post-service physical work. Nieves-Rodriguez, supra (neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service connection or rating context if it contains only data and conclusions without reasoning or rationale). As relevant to the Veteran's left knee disorder, while his private physician indicated that his knee problems are likely to have been caused by his military injury, the Veteran has not alleged an in-service left knee injury and his service treatment records are negative for any findings, complaints, or diagnoses referable to the left knee. Therefore, such private opinion is based on an inaccurate factual premise and is accorded no probative weight. Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative). The Board notes that the Veteran has contented on his own behalf that his bilateral knee disorder is related to his military service, to include his January 1970 complaints of right knee pain. In this regard, the Board acknowledges Jandreau, supra, in which it was held a layperson may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg. Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. See Woehlaert, supra (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Specifically, the etiology of an internal disorder of the knee requires specialized testing and the knowledge to interpret such tests. Indeed, diagnosing degenerative joint disease or arthritis and meniscal tears requires X-ray, MRI, or other imaging tests. There is no indication that the Veteran has the requisite knowledge to administer or interpret such tests results. Therefore, the Board finds that the Veteran is not entitled to direct service connection for his right and/or left knee disorders. The Board has further considered whether service connection on a presumptive basis is warranted. However, the record fails to show that the Veteran manifested arthritis of either knee to a degree of 10 percent within the one year following his service discharge in April 1971. Moreover, he has not provided lay evidence of a continuity of symptoms from 1971 to three years prior to treatment in 2002. As such, presumptive service connection is not warranted for arthritis of either knee, to include on the basis of continuity of symptomatology. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The Board also notes that the Veteran has claimed entitlement to service connection for a left knee disorder as secondary to a right knee disorder. However, as discussed previously, the Veteran is not entitled to service connection for a right knee disorder. As such, the Board finds that under the law, the Veteran lacks legal grounds to establish entitlement to service connection for a left knee disorder as secondary to a right knee disorder. See Sabonis, supra. In Sabonis, the Court held that in cases in which the law and not the evidence is dispositive, a claim for entitlement to VA benefits should be denied or the appeal to the Board terminated because of the absence of legal merit or the lack of entitlement under the law. Insofar as service connection is not in effect for the disability claimed by the Veteran to have proximally caused his left knee disorder, service connection on a secondary basis is not applicable under the law. As there is no legal entitlement, the claim of entitlement to service connection for a left knee disorder as secondary to a right knee disorder is without legal merit. Id. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims for service connection for right and left knee disorders. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER New and material evidence having been received, the claim of entitlement to service connection for a right knee disorder is reopened. Service connection for a right knee disorder is denied. Service connection for a left knee disorder is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs