Citation Nr: 1329767 Decision Date: 09/17/13 Archive Date: 09/25/13 DOCKET NO. 07-01 477 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a bilateral knee disorder, to include as secondary to service-connected left foot plantar keratosis. 2. Entitlement to service connection for a back disorder, to include as secondary to service-connected left foot plantar keratosis. REPRESENTATION Appellant represented by: Karl A. Kazmierzak Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD H. Yoo, Counsel INTRODUCTION The Veteran had active service from January 1987 to May 1987 and from August 1987 to November 1990. This appeal comes before the Board of Veterans' Appeals (Board) from September 2007 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In January 2010, the Veteran testified at a hearing before the undersigned at the RO. A transcript of this hearing was prepared and associated with the claims file. This issue currently on appeal was also remanded by the Board in September 2011 and September 2012 for further development. The Board is satisfied that there has been substantial compliance with the remand directives and the Board may proceed with review. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran is currently service-connected for a left foot plantar keratosis, at a 10 percent disability rating, effective November 28, 2006. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. A bilateral knee disorder was not shown in service and has not been shown by competent probative evidence to be related to a disease or injury of service origin or proximately due to the Veteran's service-connected left foot plantar keratosis. 2. A back disorder was not shown in service and has not been shown by competent probative evidence to be related to a disease or injury of service origin or proximately due to the Veteran's service-connected left foot plantar keratosis. CONCLUSION OF LAW 1. The criteria for establishing entitlement to service connection for a bilateral knee disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. The criteria for establishing entitlement to service connection for a back disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) With respect to the appellant's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 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); 38 C.F.R. §§ 3.102, 3.56(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide. The notice requirements described above apply to all five elements of a service connection claim: (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In February 2007, the agency of original jurisdiction (AOJ) provided the notice required by 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the AOJ notified the Veteran of information and evidence necessary to substantiate the claims for service connection; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. This letter also provided the Veteran with the notice pursuant to Dingess. All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (2012) (harmless error). In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claims, as well as the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service medical 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 Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The VA has obtained copies of the Veteran's service treatment and personnel records, and has reviewed the evidence in the Virtual VA system. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on a claim, as defined by law. The Veteran's service treatment records and VA medical records are in the file. Moreover, the Board finds that any underlying records in connection with the denial of benefits are irrelevant as the central question here is a nexus one which has been addressed by the medical evidence already of record. Furthermore, the Veteran has at no time referenced additional outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The record indicates that the Veteran was also afforded a VA examination in August 2007, September 2010, and October 2011, including an addendum to the October 2011 (submitted in January 2013), and the results of which have been included in the claims file for review. This examination involved review of the claims file and thorough examinations of the Veteran. Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claims. In March 2012, the Veteran had the opportunity to testify at a Board hearing at the St. Petersburg RO over which the undersigned presided. The provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the Board hearing, the undersigned clarified the issue on appeal, inquired as to the etiology of the Veteran's asserted symptoms, and asked questions that ensured no evidence was overlooked. The Veteran was offered an opportunity to ask the undersigned questions regarding his claim. The Board, therefore, concludes that it has fulfilled its duty under Byrant. The Board also finds there has been substantial compliance with its September 2012 remand directives as an addendum addressing aggravation on a secondary bases was obtained. The Board notes that the United States Court of Appeals for Veterans Claims (Court) has noted that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand.) Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remands. See Stegall, supra, (finding that a remand by the Board confers on the appellant the right to compliance with its remand orders). Therefore, in light of the foregoing, the Board will proceed to review and decide the claim based on the evidence that is of record consistent with 38 C.F.R. § 3.655 (2012). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). Importantly, the Board notes that the Veteran is represented in this appeal. See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). The Veteran has submitted arguments and evidence in support of the appeal. In addition, following the issuance of the March 2013 Supplemental Statement of the Case, the Veteran and his representative submitted a waiver of the 30 day waiting period that no additional evidence regarding the Veteran's appeal is available. As such, they requested the appeal be sent to the Board immediately. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication is not affected. II. The Merits of the Claims The Veteran claims his current back and bilateral knee disorder are related to his service-connected left foot plantar keratosis. Governing Laws and Regulations Under the laws administered by VA, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 C.F.R. § 3.303(d). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004) (citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); Caluza v. Brown, 7 Vet. App. 498, 505 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table)). Service connection may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that a Veteran had a chronic condition in service or during the applicable presumptive period. In addition, certain chronic diseases may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. For the showing of 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. If chronicity is not established, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b). However, the regulatory provisions pertaining to chronicity and continuity of symptomatology are constrained by 38 C.F.R. § 3.309(a), and thus such provisions are only available to establish service connection for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). Here, according to the Veteran's x-rays osteoarthritis was noted in the Veteran's bilateral knees and back, which is a chronic disease under 38 C.F.R. § 3.309(a) and is subject to the provisions governing service connection based upon continuity of symptomatology. Service connection may also be granted for a disability which is proximately due to or the result of a service-connection disease or injury. 38 C.F.R. § 3.310(a). Also, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. See 38 C.F.R. § 3.310(b); Libertine v. Brown, 9 Vet. App. 521, 522 (1996); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board acknowledges that the Veteran's specific contention is that his bilateral knee and back disorder is secondary to his left foot plantar keratosis. However, when determining service connection, all theories of entitlement, direct and secondary, must be considered. Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004). As such the Board will address the Veteran's claims for service connection for a bilateral knee and back disorder on both direct and secondary bases. In each case where a veteran is seeking service connection for any disability, 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 treatment records, and all pertinent medical and lay evidence. See 38 U.S.C.A. § 1154(a) (West 2002 and Supp. 2012). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has rejected the view that competent medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d. 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not always accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Factual Background and Analysis Turning to the evidence of record, the Veteran has been diagnosed with a current disability of bilateral chondromalacia in the knees and lumbar L5-S1 disc disease. According to the Veteran's in-service treatment records, there are no complaints, treatment, or diagnosis of any disorder of the bilateral knees or the back. The Veteran received treatment on his lower left leg but there is no indication there were any abnormalities pertaining to his knees and x-rays taken were negative. The Veteran's August 1990 Report of Medical Examination at separation is absent of any bilateral knee or back disorders, but there is, however, indication the he had an abnormal feet condition, namely on the left foot. Furthermore, according to the Report of Medical History at separation, also dated August 1990, the Veteran stated "everything is okay but my left foot has a fallen arch. Throbbing pain 24 hours daily and need to [fix]. Was caused by military service." The Veteran indicated he had bone, joint, or other deformity but did not indicate the specifics such as which joint or bone. The Veteran stated he did not have recurrent back pain or arthritis. He also stated he did not have a "trick" or locked knee. In January 2005, x-rays of the lumbosacral spine and thoracic spine were taken. The x-ray of the lumbosacral spine revealed the bone and joint were intact and without evidence of arthritis, facture, dislocation, or bone destruction. The impression was a normal lumbosacral spine. The x-ray of the thoracic spine revealed minimal anterior wedging of the T8 and T9 vertebral bodies with minimal osteoarthritic changes. Findings could be compatible with old minimal compression or facture. There was no demonstrable acute fracture, dislocation or bone destruction. In November 2005, the Veteran sought treatment for low back pain which he reported as an acute onset after lifting weights out of his car. The Veteran reported pain radiating down both legs, which was worse on the left. An examination revealed limited range of motion in the bilateral lower extremities and a positive straight leg raise. The VA physician noted the impression as sciatica. In February 2006, the Veteran was treated for low back and bilateral knee pain. He reported he had low back pain since November 2005 and stated he was told by a physician that he had a slipped disc. The Veteran also stated that a friend, who was a chiropractor, told him he pulled a ligament and recommended applying ice. The Veteran stated he received good results from the ice pack. The Veteran reported using lumbar support at work and reportedly fell at work before Christmas. He stated the pain initially radiated into the left buttock but he had no pain currently. The Veteran stated when he does experience pain, it is constant and dull, rated at a level of 4 or 5 out of 10. He denied radiating pain, numbness, or tingling sensation but did report morning muscle stiffness and that the "[p]ain is more at night; after [a] hard day of work." He also stated he had pain in his upper and mid back which he described as intense. A physical examination at this time revealed forward flexion of 70 degrees, extension of 15 degrees, right lateral flexion of 45 degrees, and left lateral flexion of 40 degrees. The Veteran had full strength in his lower extremities, bilaterally. He had a normal gait and was steady on a level surface. The Veteran was afforded a VA examination in August 2007 where he reported an eight year history of mid and low back pain. The Veteran stated he had been seen by physicians and treated for a chronic lumbar sacral strain. He stated the pain was typically aggravated by movement, bending, and lifting. The pain was localized with radiation into the lower extremities. He denied having x-rays taken of his back. There was no bowel or bladder incontinence. While there were no occupational affects, the Veteran's daily activities were affected in that he had difficulty getting in and out of vehicles on occasion. He reported flare-ups of increased pain and stiffness depending on the physical activity. He stated they occurred four to five times monthly and lasted two to three days. No incapacitation was noted. Regarding this bilateral knees, the Veteran reported a history of developing pain in both knees over the past two to three years and denied any trauma. The pain was diffused. He stated he was seen by his primary care practitioner regarding his knees and did undergo x-rays but was given braces. The Veteran reported the pain was intermittent, typically brought on by negotiating stairs and riding a bicycle. The Veteran denied a history of swelling or knee aspirations. There was no locking, but he reported two episodes of buckling of the right knee over the past year. Occupational effects were the same for left foot which was that the Veteran was employed as a clerk but also was on the Code Orange team. He stated he takes longer to respond to Code Orange calls and has difficulty physically restraining patients when this is deemed necessary. The daily activities affected included difficulty negotiating stairs, he cannot run greater than 200 yards, and has difficulty arising from a seated position. He has flare-ups of increased symptoms with activity which occur two to three times a month and last two to three days. There was no incapacitation. A physical examination of the back revealed the Veteran was able to heel/toe walk, his gait was normal, and there were no scars or spasms. There was bilateral paraspinal tenderness in the thoracic spine region but the straight leg raising was negative. There was no motor weakness or atrophy of the lower extremities, the deep tendon reflexes were intact, and no sensory loss to pinprick or fine touch of the lower extremities. The range of motion was 75 degrees flexion with pain at 45 degrees, hyperextension was 25 degrees with pain at 20 degrees, lateral bending bilaterally was 25 degrees with pain, rotation bilaterally was 20 degrees with pain. There was no additional range of motion loss due to pain, weakness, fatigue, lack of endurance, or incoordination following repetitive use. The Veteran was diagnosed with chronic thoracolumbar strain. A physical examination of the bilateral knees revealed a normal gait, McMurray's test was negative, there was no evidence of crepitus, deformity, erythema, effusion, instability, or tenderness. The range of motion in the right knee was 120 degrees flexion with pain and he had full extension. The range of motion in the left knee was 130 degrees without pain and with full extension. There was no additional range of motion loss due to pain, weakness, fatigue, incoordination, or lack of endurance following repetitive use. The Veteran was diagnosed with intermittent bilateral knee strain. The examiner opined the Veteran's lumbar and bilateral knee conditions were less likely than not secondary to his foot condition. The examiner stated the Veteran had scar tissue/cicatrix formation on the fourth-fifth web spaces of the left foot. The examiner stated this was not a known etiology for a throracolumbar sprain or bilateral knee sprain. According to March 2008 x-rays of the bilateral knees, the osseous and articular structures of the knees were normal. May 2008 x-rays of the bilateral knees revealed minimal increased sclerosis along the posterior cortex of the patellae bilaterally was reflective of very mild degenerative changes. The adjacent patellar cartilage as visualized on the CT appeared intact, although it was noted that the cartilage was best visualized on the MRI scan. Trace knee joint effusion was noted (greater on the right side than the left). In July 2008, the Veteran underwent a bilateral arthroscopic lateral release based on his diagnosis of bilateral chondromalacia patellae with lateral tracking patella. No opinion regarding the etiology of the bilateral knee disorder was provided. In September 2010, the Veteran underwent another VA examination where he reported pain in his foot and ankle. He stated in 2008 he placed inserts into his shoes which helped alleviate the pain in his feet but the knees became worse. He stated the pain in his constant in his knees at a 3 to 5 on a scale of 10 by the end of the day and is an 8 out of 10 with activity. The pain was worse on the right than left. He stated the pain in his left knee started in 1989 and his right knee pain started in early 1990s. The low back pain was reported as moderate to extreme on and off. He stated the lower to mid back pain started toward the end of enlistment. The Veteran stated it was his belief that the inserts in his left foot caused the knee and back problems due to the change in his gait. The foot insole was given to him in 2008. The Veteran stated the left foot insert was given to him in the military and it did not bother his knees. The examiner noted the Veteran was not wearing any prosthesis, using crutches, or braces, and the insoles were not in his shoes at the examination. There was mild limping noted in protection of the tender left foot when he walked barefooted. The tenderness was at the scar of the sole of the foot between the 2nd and 3rd toes. There was full, painless, range of motion of the knees and back. Tenderness was noted at the joint line and patella of the knees and lower back. There were no signs of radiculopathy. The Veteran had notable heel and forefoot callosities with no unusual shoe wear pattern that would indicate abnormal weight bearing but the examiner noted the shoes were not old. The Veteran had good arches in his feet with no abnormal standing phase of his gait. There were no signs of joint instability in the ankles, feet, or knees. X-rays were negative for the feet and mild osteoarthritis for the knees and spine was seen. The arthroscopy revealed chondromalacia. The examiner concluded that both bilateral knee and back pain were less likely than not caused by, or a result of, a left foot surgery or injury. Addressing the Veteran's belief that the shoe insoles prescribed in 2008 led to the deterioration of the knees and back, the examiner stated the insoles relieved his left foot problems to a great extent and there is no reason why it would make the knees and back worse. The examiner stated that if the service-connected left foot was improving from the use of the insole, the knees would also be better as the gait would have improved from the reduction of pain. There was no reason the bilateral knees and back would continue to experience symptoms. Therefore, the examiner stated he would need to resort to mere speculation in determining that the knee problems were related to the insoles of the feet. In October 2011, the Veteran was afforded another VA examination where he reported complaints of intermittent back pain induced by any activity. He had an MRI done in 2010 which revealed degenerative changes of the L5-S1. He reported his symptoms have progressively worsened. The examiner diagnosed him with lumbar L5-S1 disc disease. Regarding his knees, the Veteran stated his left knee pain started approximately 11 years ago and right knee pain approximately 7 years ago. The Veteran was diagnosed with bilateral chondromalacia. The examiner opined that the Veteran's bilateral knee condition was less likely than not secondary to the service-connected foot condition. The examiner stated the Veteran's chondromalacia was "caused by irritation of the posterior cartilage of the patella. There were many suspected causes generally attributed to overuse, overload or malalignment of the bones of the knee and foot." The examiner stated that the left foot inclusion cyst, keratosis, or the left metatarsalgia is not an etiology for bilateral chondromalacia. Regarding the back condition, the examiner stated that it is also "not related to events that occurred in military service." The examiner explained that the "cause of lumbar disc disease is unknown, although risk factors are not causative the major risk factors are aging and trauma. Obesity, smoking and a sedentary lifestyle also contribute. A left foot inclusion cyst, keratosis, along with left metatarsalgia, are not causes of lumbar disc disease." However, in September 2012, the Board determined the question of aggravation was not addressed in the October 2011 VA examination and, therefore, remanded this appeal for an addendum opinion. Therefore, in January 2013, an addendum to the October 2011 VA examination was submitted. This addendum stated that the Veteran's "lumbar L5-S1 disc disease and bilateral chondromalacia were not aggr[a]vated by the [Veteran's] left foot plantar keratosis. The [Veteran] developed both conditions after military separation with a nontraumatic onset. There is no evidence of any event regarding the [Veteran's] plantar keratosis worsening his knee and lumbar conditions." Based on the foregoing, the Board finds that the preponderance of the evidence shows that the Veteran's bilateral knee and back disorders are not related to his service-connected left foot plantar keratosis or any event in service. The evidence of record does not establish an etiological relationship between the Veteran's service-connected left foot plantar keratosis and the claimed bilateral knee and back disorders. While the VA examination indicate the presence of a current disability, there is no clear indication it is related to his military service or secondary to his service-connected left foot plantar keratosis. Similarly, while the VA treatment records also suggest a current diagnosis, there is no evidence it is related to the Veteran's military service or his service-connected left foot plantar keratosis. The Veteran also has not submitted any probative medical evidence to support his claims. The Board finds the VA opinions provided in August 2007, September 2010, October 2011, and the January 2013 addendum to be probative as to the etiology of his disorders. The VA examiners reviewed the claims file and examined the Veteran. Namely, the examiner who conducted the October 2011 VA examination and provided the January 2013 addendum, determined that the current bilateral chondromalacia and lumbar L5-S1 disc disease, was not caused or aggravated by his service-connected left foot plantar keratosis. The examiners considered the Veteran's lay statements of history, symptomatology, and theories of causation. As the VA physician was fully informed of the pertinent medical history, the opinion was fully-articulated, and supported by reasoned analysis, it is entitled to high probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008). The only evidence of record in support of the Veteran's claim consists of his own lay statements. The Board acknowledges the Veteran contentions that his bilateral knee and back disorder are related to his left foot disability. The Veteran is considered competent to report the observable manifestations of his claimed disabilities. 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). His assertions that he experiences symptoms of pain are also credible. 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, whether the Veteran's complained of symptoms are comprised of a separate and distinct disease entity that is related to his service-connected left foot plantar keratosis, 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) (providing that lay persons not competent to diagnose cancer) The Board also acknowledges that the Veteran does not allege his bilateral knee and back disorders are related to service. Indeed, there is no objective medical evidence that relates his bilateral knee and back disorders to his military service. As previously stated, the Veteran's service treatment records are absent of any complaint, treatment, or diagnosis of any bilateral knee or back abnormalities. The Veteran also stated at separation he was in good health but for his left foot. Although the Veteran has stated his condition started prior to, or soon after, separation from service, there is no evidence that his bilateral knee and back disorders were disabling to a compensable degree within one year of separation from active duty. As such, after weighing and balancing the evidence of record, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran's bilateral knee and back disorder are related to his service-connected left foot plantar keratosis, or any in-service disease, event, or injury. See 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.310. Accordingly, the Board finds that the criteria for service connection for a heart disability are not met and the Veteran's claims must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b). However, the doctrine of reasonable doubt is not for application concerning these claims as the weight of the evidence is against them. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the appeal of these claims must be denied. ORDER Entitlement to service connection for a bilateral knee disorder, to include as secondary to service-connected left foot plantar keratosis, is denied. Entitlement to service connection for a back disorder, to include as secondary to service-connected left foot plantar keratosis, is denied. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs