Citation Nr: 1328768 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 09-02 389 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a lumbar spine disorder, to include lumbar post laminectomy syndrome. 2. Entitlement to service connection for a cervical spine disorder, to include cervical spinal stenosis. 3. Entitlement to service connection for a left knee disorder, to include osteoarthritis of left knee with medial and lateral meniscal tear. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The Veteran had active service from February 1971 to February 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision of the Department of Veteran's Affairs (VA) Regional Office (RO) in Newark, New Jersey. This matter was remanded in January 2012 and May 2013 for further development. The Veteran testified before the undersigned Veterans Law Judge in a September 2011 hearing at the RO. A transcript of the hearing has been associated with the claims file. The issue of entitlement to a total disability rating based on individual unemployability has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. A lumbar spine disability was not manifested during the Veteran's active duty service or for many years after service, nor is it otherwise related to service or to the service connected right hip disability. 2. A cervical spine disability was not manifested during the Veteran's active duty service or for many years after service, nor is it otherwise related to service or to the service connected right hip disability. 3. A left knee disability was not manifested during the Veteran's active duty service or for many years after service, nor is it otherwise related to service or to the service connected right hip disability. CONCLUSIONS OF LAW 1. The criteria to establish service connection for a lumbar spine disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria to establish service connection for a cervical spine disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 3. The criteria to establish service connection for a left knee disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. 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, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters in September 2005, December 2005, and March 2006 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The March 2006 letter also explained what type of information and evidence was needed to establish a disability rating and effective date. All communications were provided prior to the adverse adjudication that is the subject of the present appeal. Accordingly, no further development is required with respect to the duty to notify. Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claims are of record, including testimony provided at a September 2011 before the undersigned. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also 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 claim. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Applicable law provides that service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. 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, such as 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. In the case of chronic diseases under 38 C.F.R. § 3.309(a), service connection may also be established by a showing of continuity of symptomatology. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet.App. 439 (1995). At the Veteran's September 2011 Board hearing, he testified that he was in a motor vehicle accident while in service, in September 1971, and that such accident was the original cause all his hip, back, and neck problems. (Vol. 4). He stated that he complained of back pain at that time but his back was never examined. The Veteran's service treatment records reflect that he sought treatment for back pain in March 1971 after lifting laundry. He was assessed with a lower back strain. There are no further entries in the service treatment records regarding the back. In September 1971, the Veteran was in a car accident in which he was thrown out of the car. He sustained a posterior dislocation of the right hip. He was discharged from the hospital in December 1971. At that time, physical examination was essentially unremarkable except for examination of the right hip, which showed tenderness to palpation over the right groin and right buttock. A January 1972 Hospital discharge report reflects that an orthopedic examination revealed that abnormalities were limited to the right lower extremity (Vol. 7). In January 1972, the Veteran underwent a Physical Evaluation Board (PEB). The examination yielded normal findings with the exception of the right hip- although range of motion was essentially normal, he continued to complain of right hip pain. Additionally, in conjunction with the January 1972 PEB, the Veteran completed a Report of Medical History. By checked box, he denied back trouble of any kind; trick or locked knee; arthritis or rheumatism; or bone, joint, or other deformity. He did state that he had swollen or painful joints. However, he specifically cited his dislocated hip (and no other joint). An August 1977 VA outpatient treatment report reflects that the Veteran sought treatment for low back pain, mostly right sided, of four days duration (Vol. 8). He was diagnosed with an acute lumbosacral strain. There we no further treatment reports regarding the low back, and there was no mention of an in-service back injury. A May 2002 treatment report from North Jersey Orthopedic Specialists, PA reflects that Veteran reported that the Veteran underwent left knee surgery in 1993 (Vol. 2, Vol. 3). The Veteran underwent back surgery in August 2002 at Holy Name Hospital (Vol. 1, Vol. 3). In November 2002, the Veteran underwent a retroperitoneal exposure of L4-5, L5-S1 at the Englewood Hospital and Medical Center (Vol. 2). An October 2002 treatment report from Neurological Surgery reflects that the Veteran reported a long history of back and lower extremity pain (Vol. 2, Vol. 6). A May 2003 cervical spine evaluation performed at the Physical Medicine and Rehabilitation Center, P.A. reflects that the Veteran complained of cervical spine pain of two years duration with no trauma (Vol. 3). He wrote that pain had been intermittent for the past two years. A June 2003 initial pain management consultation from the Physical Medicine and Rehabilitation Center, P.A. reflects that the Veteran was seen for bilateral cervical pain with radiation to the hands and arms (Vol. 2). The pain occurred over the past 6-8 months. In November 2003, the Veteran underwent partial laminectomies of T10 and T11, epidural insertion of electrodes and insertion of spinal stimulator battery, and fluoroscopic guidance (Vol. 2). A May 2004 private treatment report reflects that the Veteran complained of back pain of two days duration (Vol. 2). He thought he had overexerted himself during physical therapy. A July 2004 treatment report from Bergen Neurology Consultants reflects a history of an L4-5 disc herniation that was treated with surgery in July 2002 (Vol. 2). The report reflects that "This started after a fall in April when he was taking his luggage out of the car, slipped, fell, and hurt his back." An Englewood Hospital Med Center bill reflects a meniscus tear October 2004. (Vol. 1) A May 2005 private treatment report reflects that the Veteran injured his neck and mid-thoracic back when he slipped and fell (Vol. 2). He was discharged from Englewood Hospital and Medical Center on May 16, 2005 (Vol. 3). May 2005 correspondence from Dr. E.B. of the Physical Medicine and Rehabilitation Center, P.A., reflects that the Veteran "has a chronic left L5 radiculopathy as a result of his initial workman's comp injury, which led to lumbar disc herniation and radiculopathy." (Vol. 3). August 2005 and November 2005 correspondences from the Veteran's attorney (V.A.G.) to Dr. E.B. state that he represents the Veteran "who treated at your office for his Workers' Compensation accident of April 22, 2002." (Vol. 3, Vol. 5). In a November 2005 VA outpatient treatment record, the Veteran reported having left knee surgery in October 2005 by an outside provider. (Vol. 1) The Veteran underwent a VA examination in October 2005 (Vol. 1, Vol. 4). He reported that he was in a roll-over motor vehicle in 1971. He had dislocated his right hip and has had low back pain ever since that accident. He stated that he never reported the low back pain until it became worse in April 2002. At that time, an L5-S1 disc herniation was found. He subsequently underwent a lumbar laminectomy fusion and spinal cord stimulator implantation. The Veteran also reported that a July 2004 cervical spine MRI revealed mild cervical stenosis at C5-C6 and C6-C7. He also complained of posterior neck pain beginning in 2002. The examiner diagnosed the Veteran with cervical spine stenosis and lumbar post laminectomy syndrome with left foot drop. An October 2005 treatment report from the Spine Center and Orthopedic Rehabilitation of Englewood, P.C. reflects the Veteran's complaints of constant left knee pain. He stated that acute left knee pain began two weeks earlier (Vol. 2). An October 2005 treatment report from Holy Name Hospital also reflects complaints of left knee pain that began two years earlier (Vol. 6). A November 2005 correspondence from Dr. E. B. of the Spine Center and Orthopedic Rehabilitation of Englewood, P.C reflects that she began treating the Veteran for injuries sustained at work on April 2002 (Vol. 2). The injuries included chronic lumbar radiculopathy and nerve pain, residual low back pain, and muscle spasm. A January 2006 treatment report from the Spine Center and Orthopedic Rehabilitation of Englewood, P.C. reflects complaints of worsening low back pain since the Veteran slipped in the shower five days earlier (Vol. 2, Vol. 5). A February 2006 VA outpatient treatment report reflects that the Veteran complained of back pain since 2002 and left knee pain of one year's duration (Vol. 4). An April 2006 treatment report lists the duration of lower back and left knee pain as 5 years (Vol. 4). A June 2006 treatment report listed the duration of left knee pain as 10 months (Vol. 4). A July 2006 treatment report reflects that the back and knee pain "comes and goes" and that the duration has been more than 6 months (Vol. 4). An April 2007 treatment report stated that the Veteran has a history of low back pain from a fall in 2002 (Vol. 4). A March 2006 treatment report from the Spine Center and Orthopedic Rehabilitation of Englewood, P.C. reflects the Veteran's complaints of constant low back pain that he thought was due to an altered gait as a result of his left knee injury (Vol. 2). In March 2007, the October 2005 VA examiner submitted an addendum to his examination report. He stated that there was no documented low back pain in his claims file. He found, therefore, that it was less likely than not that the Veteran's low back disability was the result of his in-service motor vehicle accident (Vol. 4). A September 2009 treatment report written by Dr. K.J.L. states that the Veteran had chronic low back pain status post two laminectomies (Vol. 8). He stated that the Veteran "initially presented with low back pain in 2002 after a fall on his back while loading luggage into the car." The Veteran underwent another VA examination in September 2010 (Vol. 4). The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that he injured his back in the September 1971 in-service motor vehicle accident. He did not receive any medical attention for it. He reported that he had his first back surgery in 2002. He has since had multiple back surgeries. His neck pain began a few years ago. Nonetheless, he reported that it was injured in the in-service motor vehicle accident. He reported that he developed left knee pain when he got out of service. He developed left knee degenerative joint disease and had a total knee replacement in 2005. The examiner noted that a January 2007 x-ray of the injured right hip was normal. He assessed the Veteran with a right hip sprain/strain; left total knee replacement secondary to left knee degenerative joint disease; multiple lumbar spine surgeries; lumbar postlaminectomy syndrome; and, cervical degenerative disc disease. The examiner opined that the low back, cervical spine, and left knee disabilities were less likely than not related to the Veteran's right hip disability. He reasoned that the Veteran's right hip was not fractured in service and it appeared clean at the time of the examination. He did not believe the injury was severe enough to cause an altered gait severe enough to result in a lumbar condition that would require multiple surgeries. Likewise, he did not believe the in-service injury would cause an altered gait severe enough to cause accelerated degenerative joint disease of the left knee and result in a total knee replacement. Finally, he noted that even if the Veteran had an altered gait, this should not affect the cervical spine. In October 2010, the Veteran submitted a correspondence in which he stated that he injured his back in the in-service motor vehicle accident; and that it became aggravated when he was lifting laundry. (The Board notes that he hurt his back lifting laundry in March 1971; and the in-service motor vehicle accident occurred in September 1971). Consequently, the incident lifting laundry could not have aggravated the alleged motor vehicle accident back injury inasmuch as the incident lifting laundry pre-dated the motor vehicle accident. A November 2011 letter from Dr. E.B. of the Spine Center & Orthopedic Rehabilitation of Englewood, PC indicates that she had been treating the Veteran for ten years (Vol. 5). She stated that the Veteran reported lumbar back pain since he was in a motor vehicle accident at the age of 19 (while he was on active duty). He stated that he injured his right hip and his back; but that he only received treatment for his right hip. Dr. E.B. stated that the first available records available to her are dated June 10, 2002. She stated that at that time, an MRI of the lumbosacral spine revealed degenerative changes at the L4-5 and L5-S1 levels. She stated that "I believe the severe trauma suffered in 1971 could have resulted in a back injury that contributed to his right leg pain into the unexplained chronic pain that he continued to suffer even after the hip dislocation was treated. The MRI findings in 2002 are consistent with previous lumbar pathology which could have been the result of his trauma in 1971." The Veteran submitted an April 2012 correspondence from Dr. S.D. of the Center for Pain Management (Vol. 7). Dr. S.D. stated that the Veteran has been a patient of his since 2008. He further stated that the Veteran had "a history of back pain since 2002 and leg weakness." The Veteran underwent a VA examination in February 2013 (Vol. 8). The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that he dislocated his right hip and was in traction for 3-4 weeks following the September 1971 in-service motor vehicle accident. He stated that, as far as he remembered, his neck did not begin to bother him until 1976. He stated that at that time, the neck pain was intermittent but has since become persistent. He stated that he eventually sought treatment in the 2000s. The onset of his low back pain occured while the Veteran was in the hospital following the in-service accident. He stated that he didn't get the pain evaluated at that time. He reported that the back pain worsened to the point that by 1990, he sought treatment from an unknown doctor. He stated that he did not seek medical attention until 2002, when he began having pain in his buttocks. The Veteran could not recollect any knee pain while he was in the hospital (following the in-service accident). He reported that he had gradual onset of knee pain in the 1970s. He reported that he sought medical attention in 1989-1992, which led to a left knee arthroscopy. He required a total knee replacement in 2006. The February 2013 VA examiner found that it was less likely than not that the Veteran's back, neck, and left knee disabilities were related to service. With respect to the lumbar spine, she noted that there was no documentation of any lumbar problems identified in the service treatment records. She stated that she could speculate that the Veteran's "shooting pain down the lateral side of the right leg to the knee" of undetermined etiology at his January 1972 medical board was actually radiculopathy. She stated that this is suggestive of the right L5 radiculopathy that the Veteran was diagnosed with three decades later. However, she stated that without medical records from 1972-2002 and ideally a NCS/EMG, this is only speculation. With regard to the neck and left knee disabilities, she stated that there was no documentation of any neck or left knee problems in the service treatment records or for several decades after separation from service. In June 2013, the RO obtained another VA opinion. The examiner reviewed the claims file and specifically referred to the February 2013 VA examination report. He opined that it was less likely than not that the Veteran's lumbar spine, cervical spine, and left knee disabilities are related to service. He also opined that these disabilities were less likely than not caused or aggravated by his service connected right hip disability. He acknowledged the Veteran's contention that he complained about back pain in service following his motor vehicle accident. However, he noted that there was no record of it in the service treatment records. Moreover, he stated that "the scientifically based medical literature does not support an injury to a hip, even with an antalgic gait, causing aggravating (permanently worsen beyond normal progression) degenerative joint disease in other regions of the body, except for the contralateral hip." Analysis Again, in order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Veteran has established the first of these elements. Indeed, there is no doubt that he has current disabilities of the lumbar spine, cervical spine, and left knee. Regarding the second element, the Veteran sustained an injury to his low back during service when he was lifting laundry. There is considerable doubt as to whether he sustained a back injury as a result of an in-service motor vehicle accident. There is no evidence of any cervical spine symptoms or left knee symptoms during service. However, he has alleged that his cervical spine and left knee disabilities may be secondary to a service connected right hip disability. Consequently, it is not necessary for cervical spine and/or left knee symptoms to have been manifested during service. It is the third element of service connection where the Veteran's claims fall short. Chronicity in service is not adequately supported inasmuch as the service treatment records reflect only a single instance of treatment for a back disability. However, service connection may be established by continuity of symptomatology under 38 C.F.R. § 3.303(b) or based on initial diagnosis after service under 38 C.F.R. § 3.303(d). Lumbar spine In this case, the Veteran was seen on one occasion during service for complaints of back pain, so there is affirmative evidence of symptoms of a lumbar spine disability during service. As symptoms of back pain were noted during service, the principles of service connection, pertaining to chronicity and continuity of symptomatology under 38 C.F.R. § 3.303(b), apply. In support of his claim for service connection for a back disability, the Veteran has contended that he has had back pain since the September 1971 in-service motor vehicle accident, and he is competent to describe symptoms of back pain. 38 C.F.R. § 3.159 (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms, which are within the realm of one's personal knowledge, personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness). At the outset, the Board notes that following service, the Veteran sought treatment for back pain in August 1977. He was diagnosed with an acute lumbosacral strain. The Board notes the gap of approximately 5 years between the Veteran's separation from service and the first documented treatment for a back disorder. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim). The Board also notes the gap of approximately 25 years between the Veteran's August 1977 treatment and his and subsequent treatment in April 2002. However, such absence of documented treatment, in and of itself, is not a basis for discrediting his lay statements of continuity. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Thus, the Board must consider the totality of the record, and not just the absence of clinical treatment, in weighing the Veteran's statements asserting continuity of symptomatology. In this case, the Veteran's assertions are extremely inconsistent. When he sought treatment from the Bergen Neurology Consultants in July 2004, he reported a history of an L4-5 disc herniation, with surgery in July 2002. He reported that his back problems started after a fall in April (2002) when he was taking his luggage out of the car, slipped, and fell. May 2005 and November 2005 communications from Dr. E.B. of the Physical Medicine and Rehabilitation Center, P.A., reflects that she was treating the Veteran for a chronic left L5 radiculopathy that was due to a workers' compensation injury, which led to lumbar disc herniation and radiculopathy. Correspondence from the Veteran's attorney (V.A.G.) reflect that this work related injury took place in April 2002. A May 2004 private treatment report reflects complaints of back pain of two days duration. A January 2006 treatment report from the Spine Center and Orthopedic Rehabilitation of Englewood, P.C. reflects complaints of worsening low back pain since he slipped in the shower five days earlier. A March 2006 treatment report from the Spine Center and Orthopedic Rehabilitation of Englewood, P.C. reflects that the Veteran complained of constant low back pain that he thought was due an alteration of his gait as a result of a left knee disorder. A September 2009 treatment report by Dr. K.J.L. states that the Veteran had chronic low back pain status post two laminectomies. He stated that the Veteran "initially presented with low back pain in 2002 after a fall on his back while loading luggage into the car." The Veteran submitted an April 2012 correspondence from Dr. S.D. of the Center for Pain Management. Dr. S.D. stated that the Veteran had "a history of back pain since 2002 and leg weakness." The Board notes that the claims file consists of eight volumes, with numerous treatment reports. However, none of the private treatment records make any mention of an in-service injury to the Veteran's back. A November 2011 correspondence from Dr. E.B. reflects that she had been treating the Veteran for approximately ten years and that he reported lumbar back pain since he was in a motor vehicle accident at the age of 19 (while he was on active duty). This contradicts earlier communications and treatment reports, which reflect that she was treating the Veteran for injuries sustained in an April 2002 work-related accident that was the subject of a worker's compensation claim. The VA treatment records also reflect that Veteran's back pain had an onset date of 2002. Moreover, not until the Veteran's October 2005 VA examination did he attribute the back pain to an in-service motor vehicle accident. The fact that he underwent treatment from numerous private treatment facilities for years without mentioning pain during service weighs against a finding of continuity. Such statements were made in the course of seeking care, as opposed to attending an examination for the purpose of establishing disability benefits, and thus more probative weight is given these statements. Additionally, it is noted that the Veteran did not file a claim of service connection for a back disability until 2005, many decades after he separated from service. Had he been experiencing chronic back problems since service it would be reasonable to expect that he would have filed a claim sooner. Indeed, in March 1972 he sought service connection for a right hip disability. Thus, he was clearly aware of the process for applying for benefits. The fact that he did not seek service connection for a back disability at that time very strongly suggests that he was not indeed experiencing any symptoms as at that time, or that he did not associate any symptoms with active service. Moreover, the Veteran denied any back trouble when he completed his January 1972 Report of Medical History. For the above reasons continuity of symptomatology is not demonstrated here, either by the clinical record or by the Veteran's own statements. As noted above, service connection is not warranted in this case on the basis of continuity of symptomatology. However, if the competent medical evidence indicates that the current low back disorder is related to the Veteran's active service, then an award of service connection would be appropriate. In this vein, the VA examiners in September 2010 and June 2013 concluded that the Veteran's back disability was less likely as not related to service because there was no evidence of acute or chronic back injury at the time of the Veteran's separation from service. The Board finds the opinions of the VA physicians to be persuasive evidence. Indeed, the opinions were based on a review of the record and were accompanied by a clear rationale. The September 2010 opinion was offered following a physical evaluation of the Veteran. The Board acknowledges that Dr. E.B.'s November 2011 correspondence included a statement in which she opined that the severe trauma that the Veteran sustained in 1971 could have resulted in a back injury. The Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one medical professional's opinion over another, depending on factors such as reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). 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. Nieves-Rodriguez, 22 Vet. App. 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"). In regard to whether the experts were fully informed of the pertinent factual premises, the Board notes that Dr. E.B. explicitly stated that the first available records available to her were dated June 10, 2002. The Veteran informed her of an in-service motor vehicle accident. However, she had no way of knowing the severity of the Veteran's injuries because she did not have access to any contemporaneous treatment records. Moreover, she clearly was not aware that the Veteran completed a Report of Medical History in which he denied back trouble of any kind. The VA examiners on the other hand, had complete access to the claims file. With respect to whether the examiner provided a fully articulated opinion, the Board notes that Dr. E.B. did not provide one. She stated that "I believe the severe trauma suffered in 1971 could have resulted in a back injury that contributed to his right leg pain into the unexplained chronic pain that he continued to suffer even after the hip dislocation was treated. The MRI findings in 2002 are consistent with previous lumbar pathology which could have been the result of his trauma in 1971. [Emphasis added]." The Board finds that the opinion of Dr. E.B. is clearly speculative and cannot support the claim. Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim); Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship). See also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (a doctor's statement framed in terms such as "could have been" is not probative). Finally, the opinion of Dr. E.B. was not supported by a clear rationale. She simply reasoned that severe trauma to the hip could cause a back disability. She could not have been aware of the severity of the hip injury or the lack of back pain symptoms. For the forgoing reasons, the Board finds the opinions of the VA examiners to be more probative than that of Dr. E.B. Finally, the Board notes that as to the question of secondary service connection, the September 2010 and July 2013 examiners explicitly found that it was less likely than not that the Veteran's service connected right hip disability caused or aggravated his back disability. The September 2010 examiner supported his rationale by noting that the in-service injury did not result in a fracture of the hip. Consequently, he found it unlikely that it would result in a gait so altered as to be responsible for the Veteran's back disability. Likewise, the June 2013 examiner found that the scientifically based medical literature does not support an injury to a hip, even with an antalgic gait, causing aggravating (permanently worsen beyond normal progression) degenerative joint disease in other regions of the body, except for the contralateral hip. The Veteran himself believes that his current low back disorder is related to service. The Veteran is considered competent to report the observable manifestations of his claimed disability. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) ("ringing in the ears is capable of lay observation"); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (lay testimony iterating knowledge and personal observations of witness are competent to prove that claimant exhibited certain symptoms at particular time following service). However, he is not competent to opine on the diagnosis or etiology of his disability. Indeed, where a determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer.") "Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, lumbar post laminectomy syndrome falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." In sum, his statements as to etiology in this case are not competent and therefore lack probative value. As the preponderance of the evidence is against the claim under the applicable the theories of service connection under 38 C.F.R. § 3.303(b) and (d), the benefit of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). With respect to the question of entitlement to service connection on a presumptive basis, while there is medical evidence in this case of degenerative disease of the lumbar spine, there is no competent medical evidence of arthritis within one year of the Veteran's separation from active duty service, as required for service connection under 38 C.F.R. § 3.307(a), so service connection under the presumptive provisions of 38 C.F.R. §§ 3.307 and 3.309 is not warranted, and the benefit of-the-doubt standard of proof does not apply. 38U.S.C.A. § 5107(b). Neck and left knee disabilities As the service treatment records lack the documentation of manifestations sufficient to identify a chronic disability of the cervical spine and/or left knee, chronicity in service is not adequately supported by the service treatment records. Service connection may be established by continuity of symptomatology under 38 C.F.R. § 3.303(b) or based on initial diagnosis after service under 38 C.F.R. § 3.303(d). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). At the outset, the Board notes the gap of approximately 3 decades between the Veteran's separation from service and the first documented treatment for a neck or left knee disability. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. However, such absence of documented treatment, in and of itself, is not a basis for discrediting his lay statements of continuity. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). With regard to the Veteran's neck, at the October 2005 and September 2010 VA examinations, he complained of neck pain that began in 2002 and "a few years ago." At his February 2013 VA examination he stated that, as far as he could remember, his neck did not bother him until 1976. A May 2003 cervical spine evaluation performed at the Physical Medicine and Rehabilitation Center, P.A. reflects complaints of cervical spine pain of two years duration with no trauma. A June 2003 initial pain management consultation from the Physical Medicine and Rehabilitation Center, P.A. reflects that the Veteran was seen for bilateral cervical pain with radiation to the hands and arms that had occurred over the past 6-8 months. With regard to the Veteran's left knee disability, at the September 2010 VA examination, he reported that he developed left knee pain when he separated from service. At his February 2013 VA examination, he reported that he could not recollect any knee pain while he was in the hospital (following the in-service accident). He reported that he had gradual onset of knee pain in the 1970s. A May 2002 treatment report from North Jersey Orthopedic Specialists, PA reflects that the Veteran underwent left knee surgery in 1993. However, there are no contemporaneous records of such a surgery. Moreover, even a 1993 surgery would have occurred nearly two decades after service. An October 2005 treatment report from the Spine Center and Orthopedic Rehabilitation of Englewood, P.C. reflects complaints of constant left knee pain. He stated that acute left knee pain began two weeks earlier. An October 2005 treatment report from Holy Name Hospital also reflects complaints of left knee pain that began two years earlier. Thus, the post-service records do not indicate an in-service onset of left knee pain but rather indicate a variety of post-service onset dates. Additionally, it is noted that the Veteran did not file a claim of service connection for a neck or left knee disability until 2005, many decades after he separated from service. Had he been experiencing chronic neck and/or left knee problems since service it would be reasonable to expect that he would have filed a claim sooner. Indeed, in 1972 he sought service connection for his right hip disability. Thus, he was clearly aware of the process for applying for benefits. The fact that he did not seek service connection for a back disability at that time very strongly suggests that he was not indeed experiencing any symptoms at that time or that he did not attribute such symptoms to active service. For the above reasons continuity of symptomatology is not demonstrated here, either by the clinical record or by the Veteran's own statements. As noted above, service connection is not warranted in this case on the basis of continuity of symptomatology. However, if the competent medical evidence indicates that the current neck and left knee disabilities are related to the Veteran's active service, then an award of service connection would be appropriate. In this vein, the VA examiners in September 2010 and July 2013 concluded that the Veteran's neck and left knee disabilities were less likely as not related to service because there was no evidence of acute or chronic neck and left knee injuries at the time of the Veteran's separation from service. They also opined that it was less likely than not that the Veteran's cervical spine and left knee disabilities were caused or aggravated by his service connected right hip disability. The Board finds the opinions of the VA physicians to be persuasive evidence. Indeed, they were based on a review of the record and were accompanied by a clear rationale. The September 2010 opinion was offered following a physical evaluation of the Veteran. Finally, no other competent evidence of record refutes the opinions. The Veteran himself believes that his current neck and left knee disabilities are related to service. However, he is not competent to opine on the diagnosis or etiology of his disability, as they extend beyond that observable to the lay person. Where a determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer.") "Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issues in this case, cervical spine stenosis and medial and lateral meniscal tears fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." In sum, his statements as to etiology in this case are not competent and therefore lack probative value. As the preponderance of the evidence is against the claim under the applicable the theories of service connection under 38 C.F.R. § 3.303(b) and (d), the benefit of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). With respect to the question of entitlement to service connection on a presumptive basis, while there is medical evidence in this case of degenerative disease of the lumbar spine, there is no competent medical evidence of a cervical spine or left knee disability within one year of the Veteran's separation from active duty service, as required for service connection under 38 C.F.R. § 3.307(a), so service connection under the presumptive provisions of 38 C.F.R. §§ 3.307 and 3.309 is not warranted, and the benefit of-the-doubt standard of proof does not apply. 38U.S.C.A. § 5107(b). As the preponderance of the evidence is against the claim under the applicable the theories of service connection under 38 C.F.R. § 3.303(b) and (d), the benefit of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER Service connection for a lumbar spine disability is denied. Service connection for a cervical spine disability is denied. Service connection for a left knee disability is denied. ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs