Citation Nr: 1331065 Decision Date: 09/26/13 Archive Date: 09/30/13 DOCKET NO. 06-00 030A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1980 to July 1982. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions dated in July 2004 and November 2004 by the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut, which denied the benefits sought on appeal. In March 2006, the Veteran provided testimony at a hearing before a Decision Review Officer (DRO) at the RO. In January 2007, the Veteran also testified at a conducted by the use of video conferencing equipment at the Hartford, Connecticut RO before the undersigned Veterans Law Judge (VLJ) sitting in Washington, D.C. Transcripts of those hearings have been associated with the claims file. This case was previously before the Board in March 2007, June 2010, November 2011 and January 2013 and was remanded for additional development. For the reasons discussed below, the Board finds that there has been substantial compliance with its prior remands. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. The Veteran's right knee disability was noted at entrance into active service. 2. The Veteran's right knee disability did not undergo a permanent worsening during or as a result of service. 3. The Veteran's left knee disability is not related to his military service. CONCLUSIONS OF LAW A right knee disability was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1111, 1131, 1153, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.159, 3.303, 3.304, 3.306 (2012). A left knee disability was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under 38 U.S.C.A. § 5102 VA first has a duty to provide an appropriate claim form, instructions for completing it, and notice of information necessary to complete the claim if it is incomplete. Second, under 38 U.S.C.A. § 5103(a), VA has a duty to notify the claimant of the information and evidence needed to substantiate and complete a claim, i.e., existence of a current disability, the degree of disability, and the effective date of any disability benefits. The appellant must also be notified of what specific evidence he is to provide and what evidence VA will attempt to obtain. Third, VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. This includes obtaining all relevant evidence adequately identified in the record and, in some cases, affording VA examinations. 38 U.S.C.A. § 5103A. In Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006), the United States Court of Appeals for Veterans Claims (Court) observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (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. See 38 U.S.C. § 5103(a). The Board finds that the RO's letters dated in May 2004 and April 2007 provided the Veteran with notice that fulfills the provisions of 38 U.S.C.A. § 5103(a) including notice of the laws and regulations governing disability ratings and effective dates as required by the Court in Dingess, 19 Vet. App. at 490. Even if the Veteran was not provided the Dingess notice prior to the initial adjudication of the claims, the Board finds that providing him with adequate notice in the April 2007 letter followed by a readjudication of the claims in the December 2008, June 2011, August 2012, and March 2013 supplemental statements of the case (SSOCs) "cures" any timing problem associated with inadequate notice or the lack of notice prior to the initial adjudication. Mayfield v. Nicholson, 20 Vet. App. 537 (2006). The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records and post service medical records, as well as his records from the Social Security Administration (SSA). 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In compliance with the Board's remands in March 2007, June 2010, November 2011, a VA examination was provided to the Veteran in December 2011 and a medical opinion was obtained in connection with the issues decided herein. 38 C.F.R. § 3.159(c) (4). The medical opinion was based on a review of the Veteran's claims file and consideration of the Veteran's lay statements and the examiner provided a conclusion supported by a rationale. Therefore, it was adequate for VA purposes. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Further, pursuant to the Board's January 2013 remand, the RO verified the Veteran's current address and resent a copy of the June 2011 and August 2012 SSOCs to the Veteran. Under these circumstances, the Board finds that there has been substantial compliance with its prior remands. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders, 129 S. Ct. 1696 (2009). 38 C.F.R. § 3.103(c)(2) (2012) requires that the DRO who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the DRO hearing, the Veteran was assisted at the hearing by an accredited representative from the American Legion. The representative and the DRO asked questions to ascertain to ascertain the onset of symptoms, duration of symptoms, and any nexus between current disabilities and service. No pertinent evidence that might have been overlooked and that might substantiate the claims was identified by the Veteran or the representative. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that the DRO complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). During the Board hearing, the representative and the VLJ asked questions to ascertain the extent of any in-service event or injury and whether the Veteran's current disabilities are related to his military service. On remand, a VA examination was conducted; otherwise, no pertinent evidence that might have been overlooked and that might substantiate the claims was identified by the Veteran or the representative that has yet to be obtained. The hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for service connection. Therefore, the Board finds that the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c) (2). In adjudicating the claims below, the Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Law and Analysis The Veteran contends that his bilateral knee disability is related to service. Specifically, in his original application for compensation benefits, received by VA in April 2004, he alleged that his knee problems began in September 1979 while in the 'military boot camp.' During his January 2006 DRO hearing, he testified as to an in-service incident where he injured his right knee on the log while running through an obstacle course during basic training some time after September 1980. He stated that he was told that he fractured his right knee and he was put on a P3 profile for about 4 days then back to active duty. He further stated that "the injuries kept reoccurring for the next, for the past 20 years." During his January 2007 hearing before the Board, the Veteran asserted that his right knee disability was a result of his military service, twist-type injuries in 1980, in particular. He then testified as to the incident involving the right knee injury during an obstacle course. He believed that that injury was "the one that did the, the tearing." He also mentioned "the bunk injury." With regard to the left knee, the Veteran claimed that his left knee condition was secondary to his right knee. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b); also see Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013) (holding that the provisions of § 3.303(b), however, only apply to the list of disabilities identified under § 3.309(a)). 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). In order to establish direct service connection for a disorder, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent." However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). The law provides that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1110, 1111 (West 2002). Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b) (2012). When no pre-existing condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both pre-existing and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any "increase in disability [was] due to the natural progress of the pre-existing condition." 38 U.S.C. § 1153. If this burden is met, then the veteran is not entitled to service-connected benefits. However, if the government fails to rebut the presumption of soundness under 38 U.S.C.A. § 1111, the veteran's claim is one for service connection. Conversely, if a pre-existing disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. See Wagner, 370 F. 3d at 1094-1096. In that case, 38 U.S.C.A. § 1153 applies and the question becomes whether the disability worsened in service. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation under 38 U.S.C.A. § 1153 arises, the burden shifts to the government to show a lack of aggravation by establishing "that the increase in disability is due to the natural progress of the disease." 38 U.S.C. § 1153; see also 38 C.F.R. § 3.306 (2006); Jensen, 19 F.3d at 1417; Wagner, 370 F. 3d at 1096 (Fed. Cir. 2004). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. 1153; 38 C.F.R. 3.306(b); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition itself, as contrasted with mere symptoms, has worsened. See Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). In this case, the presumption of sound condition on service entrance does not apply with regard to the Veteran's right knee, because there is evidence prior to service entrance that he had injured his right knee in June 1980 while playing basketball as noted in his service enlistment examination wherein he complained of pain, tenderness, limited motion and prepatellar edema involving the right knee. Additionally, an August 1980 consultation report notes an impression of mild internal derangement, but with normal X-ray findings. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b). The issue thus becomes whether the Veteran's pre-existing right knee disorder was aggravated during or due to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. In a December 1980 service treatment report, the Veteran reported that he fell off the bunk the previous night and twisted his right knee. He complained pain in the right knee. History of trauma to the right knee in the past was noted. The assessment was right knee ligament sprain. Treatment plan included application of ACE wraps, ASA, profile for 24 hours, heat, elevation, and exercise. In January 1981, the Veteran continued to complain of painful right knee for months and pain upon ambulation. He stated that doing physical training or excessive marching increased current condition. The assessment was right knee ligament strain due to training. Service treatment records further reflect that the Veteran was seen for pain to the head and body after being assaulted in December 1981. He had bruise in the right knee; however, no diagnosis was made with regard to the right knee. Service separation examination conducted in June 1982 is negative for any knee complaints or diagnoses. In the medical history, the Veteran denied "trick" or locked knee. After separation from service, a November 2003 private treatment record shows the Veteran's complaints of occasional dislocation of the right knee. In a June 2004 private treatment report, the Veteran reported a blunt injury. He complained of right knee pain and "giving out" while walking and falling. Objectively, right and left knee valgus deformity was shown. It was noted that a May 2004 magnetic resonance imaging (MRI) of the knees revealed torn anterior cruciate ligaments (ACLs) on both knees. Private treatment records from the University of Connecticut (UConn.) Health Center, covering the period from May 2005 to April 2006, reflect that the Veteran complained of instability in both his knees in May 2005. It was noted that he had ACL deficiencies in both knees for at least 10 years now; however, the condition had been getting worse. In June 2005, he underwent a right knee ACL reconstruction, with a diagnosis of right knee ACL tear with likely medial meniscal tear versus deficiency. In February 2006, he also underwent a left knee ACL reconstruction with a diagnosis of left ACL tear. In an October 2006 letter, Dr. A.M. from the UConn. Health Center indicated that he reviewed the Veteran's service treatment records. Dr. M. further stated There is no question that [the Veteran] started complaining of knee pain on 8/5/80. ... However, this mechanism of injury at this time was not consistent with the same mechanism that he had on December 14, 1980 when he fell out of the bunk and had a twisting injury. At that time he was diagnosed with a right "knee ligamental sprain." Approximately 4 weeks later he was seen with almost the same injury in the right knee with difficulty in walking and pain. [The Veteran] is being consistent with his complaints in his right knee, happening from either activities while in the military service or while falling out of the bunk. Dr. M. concluded that the right knee disability, which is a chronic ACL tear, was due to these twisting-type injuries in the 1980. He added that the Veteran complained of the chronic ACL tear which was indeed what was found. On a September 2008 VA examination, the Veteran gave a history of injuring his knees on active duty in basic training. He reported running full throttle, leaping and landing on his knee on a log in the right knee. He also reported he fell off the bunk the night before his December 14, 1980 treatment and twisted his right knee. The examiner noted that the Veteran's right knee injury was noted prior to his enlistment in the Army but opined that bilateral knee conditions were less likely related to the Veteran's injury while on active duty because the injuries were diagnosed as knee strains/sprains which responded to treatment prescribed and the Veteran was able to return to full duty. In its June 2010 remand, however, the Board found that this medical opinion was incomplete on the matter of whether the Veteran's right knee disorder was aggravated by his period of service beyond natural progression of the disease. Accordingly, the Veteran was afforded another VA examination in November 2010 and a February 2011 addendum to that examination was obtained when the claims file was subsequently made available to the examiner to review. However, in both the November 2010 examination report and the February 2011 addendum, the VA examiner, relying on the Veteran's reported history of no pre-existing right knee injury, did not address the issue of whether the Veteran's right knee disorder was aggravated by his period of service. Therefore, the Board again remanded the case for a new VA examination, which was obtained in December 2011. The VA examiner indicated that the claims file was reviewed. The examiner considered the Veteran's reports as noted as follows: In 1980, [the Veteran] smashed his right knee during the obstacle course, going full throttle, he was put on [P3] profile. He also had injury prior to getting into service playing basketball. While during the obstacle course landed on his right knee on the log (8/5/1980) impression was mild internal derangement. 12/14/80: fell off the bunk and hurt his right knee, assessment: right knee ligamentous strain. He was also assaulted by some fellow in December 1981 while in the dorm, he was fighting and claimed he hurts his right knee. The Veteran reported that his left knee was already hurting in 1982 when he was discharged from service. He lived with the pain but never sought medical treatment until in the year 2000s. He also related that after separation from service, he had worked in Emergency Medical Service (EMS) for 15 years and this job entailed running, jumping, leaping, and lifting. He quit working in EMS in 2003, at which time he sought consultation with orthopedics. The Veteran denied trauma to the left knee when he left service and claimed that his left knee pain is from favoring the right knee because of pain. Based on a thorough review of the evidence in the claims file and a clinical examination of the Veteran's knees, as well as consideration of his reported history, the examiner opined that "the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness." In support of this opinion, the examiner provided the following rationale: [T]here was no complaints of knee pains until 2004. [The Veteran] had worked as an emt [(emergency medical technician)] for 15 years where this would entail running, jumping and leaping to help patients. His pathology can also be attributed to the aging process. With regard to the right knee, the examiner specifically opined that it is less likely that the in-service incidents aggravated the Veteran's right knee condition. In reaching this conclusion, the examiner noted in part that there was no hospital visit or provider visit in the 1980s or 1990s after his separation from service regarding his knees. The examiner further noted that it is more likely that the aging process and the Veteran's job as an EMT had contributed to the further progression of the disease. The examiner added that the left knee pathology is less likely as not a result of the Veteran's right knee pathology. As noted above, the presumption of sound condition on service entrance does not apply with regard to the Veteran's right knee disability, and the issue presented is whether the Veteran's pre-existing right knee disability was aggravated during or due to service. The Board notes that right knee complaints and diagnoses were documented in service and considered the Veteran's reports of multiple right knee injuries in service. However, the December 2011 VA examiner opined that it is less likely that these in-service incidents aggravated the Veteran's right knee condition. In reaching this conclusion, the examiner noted that there was no hospital visit or provider visit in the 1980s or 1990s after the Veteran's separation from service regarding his knees and that it is more likely that the aging process and the Veteran's job as an EMT had contributed to the further progression of the disease. The Board finds that this VA opinion to be competent, highly probative medical evidence as to whether the Veteran's pre-existing right knee was aggravated by his service. It was based on a thorough review of the Veteran's records, including his lay statements, and was supported by an adequate rationale consistent in finding that there was no permanent aggravation. It appears that Dr. M. reached the opposite conclusion in his October 2006 letter when he stated that "the mechanism of injury [on August 5, 1980, which is prior to service] was not consistent with the same mechanism that [the Veteran] had on December 14, 1980 when he fell out of the bunk and had a twisting injury." Service treatment records do not reflect any injury on August 5, 1980; rather, it was noted that following the Veteran's complaints of pain, tenderness, and limited motion after a right knee injury on June 22, 1980, he was found to have mild internal derangement of the right knee on an August 5, 1980 consultation. Indeed, there is no notation as to the type or the mechanism of the June 1980 basketball injury. However, Dr. M. failed to provide further explanation for his conclusion that the June 22, 1980 injury and the December 14, 1980 injury involved different mechanisms. See Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.") Thus, his opinion remains inconclusive as to whether the Veteran's right knee disorder that preexisted his service was aggravated in service. Further, Dr. M. stated that "[a]pproximately 4 weeks later he was seen with almost the same injury in the right knee with difficulty in walking and pain," and concluded that the right knee disability was due to "these twisting type injuries" in the 1980. He essentially implicates that the Veteran sustained another twisting-type injury in January 1981. However, the January 1981 service treatment report simply reflects that the Veteran continued to complain of painful right knee and the assessment was right knee ligament strain due to training, not another twisting type injury. Although Dr. M. indicated that he reviewed the Veteran's service treatment records, his opinion was based upon inaccurate factual premise. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (holding that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion); but see Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that review of the claims file by a VA examiner does not automatically render the opinion persuasive, because the central issue is whether the examiner was informed of the relevant facts in rendering a medical opinion). While both the December 2011 VA examiner and Dr. M. are competent to offer an opinion as to the etiology of the Veteran's right knee disability and the Board has no reason to doubt the credibility of either medical professional, the Board attaches a far greater probative value to the opinion of the December 2011 VA examiner for the reasons explained above. As such, the Board finds that there was no evidence of permanent aggravation of the Veteran's preexisting right knee disability. In other words, the right knee symptomatology shown in service was acute exacerbations that do not constitute aggravation. With respect to the Veteran's claim for left knee disability, service treatment records are entirely negative for any left knee condition, and the Veteran denied any specific left knee injury in service. Thus, there is no demonstration of any event in service to which the current disability at issue may be etiologically linked. On the December 2011 VA examination, the Veteran reported that his left knee was already hurting when he left service. However, after considering the Veteran's reported history, the December 2011 VA examiner opined that the Veteran's left knee disability was "less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness," because there was no complaints of knee pains until 2004 and because the Veteran had worked as an emt for 15 years which entailed running, jumping and leaping to help patients. The examiner further stated that the left knee pathology was attributable to the aging process. There is no contrary medical opinion of record. The Veteran is certainly competent to testify as to symptoms that are non-medical in nature, such as knee pain. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology that is not medical in nature); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (certain disabilities are not conditions capable of lay diagnosis). However, to the extent that the Veteran contends that his right knee disability that existed prior to service was permanently aggravated by service or that his left knee disability was incurred in service, he has not demonstrated that he is qualified through specialized education, training or experience to offer an opinion in medical matters. While there is no bright line exclusionary rule that a lay person cannot provide opinion evidence as to a nexus between an in-service event and a current condition, not all medical questions lend themselves to lay opinion evidence. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In Davidson, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) referred to Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) for guidance. In footnote 4 of Jandreau, the Federal Circuit indicated that the complexity of the claimed disability is to be considered in determining whether lay evidence is competent. The Board finds that the etiology of the Veteran's bilateral knee disability is too complex an issue, one typically determined by persons with medical training, to lend itself to lay opinion evidence. Thus, the Veteran is not competent to render a medical diagnosis or etiology of diseases involving the joints is not observable but concerns the pathological process within the body. The question of etiology in this case requires medical evidence. Such evidence is against the claims in this case. Further, any probative value in the Veteran's lay opinion regarding the etiology of his bilateral knee symptoms is outweighed by the opinion of the December 2011 VA examiner who is a medical professional. Accordingly, the Board concludes that the Veteran's right knee disability was present at service entrance, and was not aggravated during or due to service. The Board also concludes that the Veteran's left knee disability was not incurred during or due to his service. As the preponderance of the evidence is against the claims, the benefit of the doubt rule is not applicable, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied. ______________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs