Citation Nr: 1332024 Decision Date: 10/03/13 Archive Date: 10/07/13 DOCKET NO. 07-25 483 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected right knee disabilities. 2. Entitlement to service connection for a left hip disorder, to include as secondary to service-connected right knee disabilities. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.R. Bryant, Counsel INTRODUCTION The Veteran served on active duty from March 1976 to March 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision issued by the above Department of Veterans Affairs (VA) Regional Office (RO). The appeal was most recently Remanded by the Board in June 2013, for additional evidentiary development and readjudication. Such development having been completed, it has been returned to the Board for further appellate review. In December 2009, the Veteran testified at a hearing before the undersigned Veterans Law Judge at the Atlanta RO. A transcript of the hearing has been associated with the claims file. The Board also notes that VA medical records, available through the Compensation and Pension Records Interchange (CAPRI), were uploaded to the Veteran's electronic Virtual VA folder and considered by the RO in the most recent Supplemental Statement of the Case. Because the current appeal includes records that are located only in the Virtual VA system, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. A chronic left knee disorder was not present in service and degenerative joint disease did not manifest to a compensable degree within one year of service discharge; and, the preponderance of the evidence fails to establish that any diagnosed left knee disorder, is causally or etiologically related to service in any way or to any service-connected disability. 2. A chronic left hip disorder was not present in service and degenerative joint disease did not manifest to a compensable degree one year of service discharge; and, the preponderance of the evidence fails to establish that any diagnosed left hip disorder is causally or etiologically related to service in any way or to any service-connected disability. CONCLUSIONS OF LAW 1. A left knee disorder was not incurred in or aggravated by service, and degenerative joint disease may not be presumed to have been incurred in service and is not proximately due to or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307(a)(3), 3.309(a), 3.310 (2013). 2. A left hip disorder was not incurred in or aggravated by service, and degenerative joint disease may not be presumed to have been incurred in service and is not proximately due to or aggravated by any service-connected disability. 38 U.S.C.A §§ 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in January 2006, of VA's duty to assist him in substantiating his claims under the VCAA, and the effect of this duty upon his claims. Although this initial letter did not comply with all dictates of Dingess, because service connection is being denied for the claimed disabilities, any question as to the appropriate disability rating or effective date ultimately is moot. Thus, even non receipt of notice concerning these downstream elements of these claims is, at most, nonprejudicial, i.e., harmless error. 38 C.F.R. § 20.1102. VA has also satisfied its duty to assist the Veteran in the development of the service connection claims adjudicated herein. The Board has reviewed both the Veteran's physical claims file and the file on the Virtual VA electronic file system, to ensure a total review of the available evidence. Pertinent in-service and post-service treatment reports are of record. The Veteran has availed himself of the opportunity to submit relevant documents and argument in support of his claims, including personal statements, representative argument, and has provided testimony at the 2009 Board hearing. The Board finds that there is no additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. The Board is also satisfied that the AMC has substantially complied with its most recent June 2013 remand directives as they pertain to the service connection matter decided herein. Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). As instructed by the Board, the AMC/RO obtained medical comment concerning the etiology of the Veteran's diagnosed left knee and left hip disorders to include whether they are aggravated by his service-connected right knee disabilities. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the 2013 VA opinion is more than adequate, as it reflects a full review of all medical evidence of record, is supported by sufficient detail, refers to specific documents to support the conclusions reached, and also addresses service connection on both a secondary and aggravation basis, as required by 38 C.F.R. § 3.310. There is also no medical evidence of record that suggests a nexus between any currently diagnosed left knee or left hip disorders and military service; nor has the Veteran provided credible evidence of continuity of symptomatology since separation from service. Accordingly, there is no basis to conclude that the 2013 VA medical opinion is inadequate, or that a remand for a new examination is required. Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Discussion of the Veteran's December 2009 Travel Board hearing finally is necessary. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here. The issues of entitlement to service connection for left knee and left hip disorders were identified. Information was elicited from the Veteran concerning the etiology and onset of his left knee and left hip disorders. Such triggered the Board's determination that a Remand was necessary to provide the Veteran with a more detailed and responsive medical opinion. Additional VA treatment records were also identified, which were requested and obtained. Accordingly, the Board finds that VA has satisfied its duty to assist the Veteran in apprising him of the evidence needed, and in obtaining evidence pertinent to his claims. No useful purpose would be served in remanding this matter for yet more development. A remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit to the Veteran. 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); & Quartuccio v. Principi, supra. Law and Analysis The Veteran seeks service connection for left knee and left hip disorders that he contends were caused, or made worse, by his service-connected right knee disabilities. See VA Form 21-4138, received in November 2005. He presents evidence showing diagnoses of degenerative joint disease of the left knee and left hip. Further, as noted, there are service treatment records that suggest that the Veteran experienced left knee problems during service. The claims for direct service connection were also denied during the course of this appeal. See Rating Decision dated in May 2006. Thus, while the Veteran has primarily limited his argument to principles of secondary service connection, the Board will analyze the claims on both direct and secondary service connection bases. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). "To establish a right to compensation for a present disability, a Veteran 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"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). Service connection for certain specified chronic diseases, such as arthritis, may be established on a presumptive basis by showing that they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). 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. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). (holding that the term "chronic disease in 38 C.F.R. § 3.309(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). A grant of service connection under 38 C.F.R. § 3.303(b) does not require proof of the nexus element; it is presumed. Id. Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). In order to establish service connection for a claimed secondary disorder, there must be medical evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). Service connection is currently in effect for right knee instability with strain and mild degenerative joint disease of the right knee, each rated as 10 percent disabling. After considering all information and lay and medical evidence of record in a case with respect to benefits under laws administered by the Secretary, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The benefit of the doubt rule is inapplicable when the evidence preponderates against the claim. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Turning to the evidence in the current appeal, service treatment records show that the Veteran was evaluated for complaints of left knee pain and swelling variously attributed to muscle strain, chondromalacia patella, and jumper's knee. X-rays were normal. See service treatment records dated in April 1977, November 1977 and January 1978. At his separation physical, given the opportunity to identify any additional history or symptoms associated with the in-service complaints, there was no reference to any left knee abnormalities, problems or impairment of any sort. See January 1979 Report of Medical Examination. In fact, in the physician's summary of defects and diagnoses section of the report, the only abnormality highlighted was chondromalacia of the right patella. These service records also show the Veteran did not indicate any specific left hip symptomatology during service, and none is documented. Notwithstanding the foregoing, there are two medical opinions from a private physician that suggest that the Veteran's right knee "may have caused" his left knee and left hip pain. See statements (VA Forms 21-4138) from S. Khair, M.D. dated in October 2005 and November 2005. The Board notes that while the private physician has indicated a causal link between the Veteran's left knee and left hip problems, and his service-connected right knee, both opinions are fairly cursory in that no rationale was given and they were not accompanied by any clinical findings in support. When examined by VA in March 2006, the Veteran gave a history of a left knee pain, stiffness, weakness, swelling, redness, giving way, locking, and dislocating. He noted the onset of these symptoms four years ago after he tripped, putting all of his weight on one knee. The Veteran also complained of a history of hip pain and stiffness, with prolonged sitting or standing, which he noticed when he began shifting weight from one leg to the other because of his knee conditions. The Veteran had a brace on both legs and walked with both legs in a stiff position. The examiner noted that accurate range of motion testing could not be performed because the Veteran would not relax the left knee. The left knee remained in a stiff position at 20 degrees of joint flexion and 20 degrees of joint extension, but was not ankylosed. Examination of the left hip was essentially normal, but flexion was significantly limited. X-rays of the left knee and left hip were within normal limits with no evidence for fracture or other significant bone or soft tissue abnormality. The examiner reported that he was unable to answer whether or not the Veteran had left knee and hip conditions secondary to his service connected right knee condition. He noted that the Veteran's normal X-ray findings did not correlate with the examination findings. He explained that for the range of motion to be that severely decreased the X-rays more likely would not be normal, suggesting malingering. See March 2006 QTC examination report. Additional X-rays taken by VA in July 2006 confirmed that there was no evidence of arthritis of the left knee. There was no evidence of acute fracture, dislocation, or destructive process. The joint spaces were well preserved and bone density was normal. There was no evidence of joint effusion and the soft tissues were unremarkable. The Veteran countered the March 2006 VA examiner's charge of suspected malingering by submitting opinions from his private physician. Dr. DelVecchio noted that the Veteran was actively receiving treatment for instability, weakness, and painful range of motion of the left knee and left hip. He added that the Veteran had been fitted with rigid knee braces on both knees and was also using a cane to help with ambulation. See statements from P.A. DelVecchio, M.D. dated in September 2007 and March 2009. The Veteran essentially argued that his record of treatment supported the finding that he had a current disability and that he was not malingering. In its June 2010 Remand, the Board directed the VA examiner to discuss the private medical opinions of record which indicated that that the Veteran's left knee and left hip pain may be from his chronic right knee pain. The VA examiner was also asked to discuss the March 2006 VA examiner's conclusion that an opinion could not be rendered on the issue of whether the Veteran's disorders were related to his service-connected right knee disabilities because it was determined the X-ray findings did not correlate with the physical examination and, as such, malingering was suspected. The Veteran was scheduled for VA examination in July 2010. At that time the VA examiner reviewed the claims file, including service treatment records and post-service VA outpatient treatment reports and summarized the history and findings reflected by these records. The examiner noted the Veteran had undergone five examinations, none of which identified any specific disease in the left knee. During the examination the Veteran maintained his left knee in an extended position with flexion limited to 15 degrees with pain. However the examiner observed that while dressing and undressing, the Veteran could achieve an estimated flexion of 80 degrees. X-rays of the left knee showed some early degenerative joint disease. Examination of the left hip was unsatisfactory as the Veteran kept his knee extended. While the Veteran could rotate the hip and get some range of motion the examiner was not able to quantify these movements. There was no evidence of flexion contracture and the Veteran had satisfactory extension. There was left hip tenderness around the greater trochanter area and above. An X-ray of the left hip was normal, but a bone scan showed uptake in both hips although the Veteran was complaining of pain only on the left side. The clinical impression was mild left knee degenerative joint disease, which was less likely as not caused by or aggravated by the Veteran's service-connected right knee condition. The examiner noted that on the surface the Veteran's left knee disability was severe in that he had a great deal of difficulty walking and needed a brace. However the examiner was uncertain about the degree of objective problems in that the Veteran kept his left knee extended and did not use any external support such as crutches or canes. He explained that these were confounding data points since if the Veteran had considerable left knee pain, the extended position would be painful and would require external support such as canes or crutches or walkers, which Veteran did not. The examiner was unable to identify any objective pathology in the left hip or provide a diagnosis other than normal left hip. However following a thorough review of the July 2010 VA examination report, the Board found that the examiner had not discussed the private opinions or the implications of the March 2006 VA opinion. See Board Remand, February 2012. To address the inadequacies in the July 2010 VA opinion, the Veteran underwent additional VA examination in March 2012. Following a review of the claims folder and an examination of the Veteran, the examiner concluded that the current left knee and hip disorders, diagnosed as arthralgia were not secondary to the Veteran's service connected right knee disabilities. The examiner opined that while the X-rays findings were consistent with minimal early degenerative joint disease of the left knee and left hip, this was considered more compatible with age. Unfortunately, the examiner failed to address the question of whether the Veteran had additional disability resulting from aggravation of his left knee and left hip disorders, by his service-connected right knee disabilities. In June 2013, the claims file was returned for an additional medical opinion. Following an additional review of the claims folder, including the previous VA examination reports and medical opinions from the private treating physicians, the examiner confirmed that the Veteran's claimed left knee and left hip conditions were less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected right knee disabilities. The examiner referred to the private physician's statements regarding causation and aggravation, noting that the opinions were provided without any rational. With regard to the Veteran's possible malingering, he noted that none of the past examinations had shown the Veteran to have effusions in the knees or instability and X-rays of the knees and hips have been normal. Although in recent years there have been minimal findings of degenerative joint disease, these are compatible with age. The examiner concluded that other than limitation of flexion, the Veteran's service-connected right knee had no evidence of significant objective disease. Likewise there was also no evidence of significant objective disease in the left knee and left hip. Hence, it was less likely than not that the Veteran's right knee causes or aggravates his left knee and left hip. Based on the evidence in this particular case, the Board finds that service connection for a left knee disorder and a left hip disorder is not warranted. While none of the VA opinions of record provide a positive opinion with regard to the Veteran's claim, the Board considers the June 2013 addendum opinion the most probative and persuasive medical evidence in this case, as it is based upon a complete review of the Veteran's entire claims file, sets out the most helpful and complete discussion of the medical questions, and is supported by detailed rationale. Specifically, the VA examiner considered the Veteran's history of left knee and left hip symptomatology, the relevant history as contained in medical records, the findings from previous clinical evaluations, and discussed the Veteran's symptoms in the context of that history. Also considered was the Veteran's belief that his left knee and left hip problems were the result of or caused by his service connected right knee disabilities. Thus he had sufficient facts and data before him and was able to address fully the salient question as to the origin of the Veteran's current left knee and left hip problems and their relationship to his service-connected right knee disabilities. This is particularly important, in the Board's judgment, as the VA examiner's references and specificity make for a more persuasive rationale. In addition, the opinion is highly probative because it reconciles all of the prior opinions and other medical evidence of record. Careful consideration has also been given to the opinions of the private physician as to the nature and etiology of the Veteran's left knee and left hip disorders. The Board is cognizant that the physician had clearly evaluated the Veteran at some point and thus was well aware of his conditions and the medical treatment for them. However, these private opinions, while supportive of the claim, are limited in terms of their ultimate probative value as they are fairly cursory in that the physician did not explain what evidence in the Veteran's treatment records supported his conclusions, and did not reference any clinical data or other evidence as rationale for the opinion. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and provides sound reasoning for the conclusion). For example, the physician stated that the Veteran's chronic right knee pain "may have caused" the left knee and left hip pain, but pointed to no evidence to support that finding. The Board observes that such general statements regarding etiology do not have enough probative value to suggest a specific link between the currently diagnosed degenerative joint disease involving the left knee and left hip and the Veteran's service-connected right knee disabilities. The private opinions are further weakened as at best, the private physician does little more than indicate the possibility that the Veteran's left knee and left hip problems are related to his service-connected right knee disabilities. A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty for an assessment. See Morris v. West, 13 Vet. App. 94, 97 (1999) (diagnosis that appellant was "possibly" suffering from a disability was deemed speculative); Bloom v. West, 12 Vet. App. 185, 187 (1999) (physician's opinion that service experience "could have" precipitated disability found too speculative); see also Obert v. Brown, 5 Vet. App. 30, 33 (1993) (physician's statement that veteran "may" have had pertinent symptoms also implied "may or may not" and was deemed speculative). Such speculation is not legally sufficient to establish service connection. See Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). See also 38 C.F.R. § 3.102 (reasonable doubt does not include resort to speculation or remote possibility). Therefore, after weighing the medical evidence of record, the Board finds greater probative value in the 2013 VA opinion. This negative nexus opinion is sufficient to satisfy the statutory requirements of producing an adequate statement of reasons and bases where the expert has fairly considered material evidence which appears to support the Veteran's position. Wray v. Brown, 7 Vet. App. 488, at 492-93 (1995). The private medical opinions, while not discounted entirely, are entitled to less probative weight in the face of the remaining evidentiary record. The Board is also unable to attribute the development of any left knee or left hip disorder to the Veteran's military service. The service treatment records, as a whole, provide negative evidence against these claims. They show neither complaints nor evidence of chronic left knee and left hip disorders in service. The Veteran was seen on a few occasions for acute left knee symptoms in service and was later cleared for discharge without there being any mention of a left knee problem. There is also no evidence that degenerative joint disease (arthritis) was manifested in the first post-service year. Moreover there follows a period of about 30 years during which the Veteran did not complain of or receive treatment for any pertinent left knee and left hip symptoms consistent with 38 C.F.R. § 3.303(b). Although not a dispositive factor, the significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000). Reference is also made to the fact that the Veteran made no mention of a left knee disability at the time he filed his original claim for benefits in February 2002. He submitted his claim for service connection for right knee disability at that time. Had he been experiencing chronic left knee problems since service, as he had claimed with his right knee, there seems to be no logical reason for not mentioning his left knee. There was What remains for consideration is whether or not in the absence of a diagnosis in service and/or continuity of symptoms the Veteran's diagnosed degenerative joint disease of the left knee and left hip may nonetheless somehow otherwise be related to his service. However, there is no competent medical evidence linking the Veteran's diagnosed degenerative joint disease to his military service years earlier, and he has not submitted any medical opinion that relates them to his service/events therein. See Hickson v. West, 12 Vet. App. 247. In reaching these conclusions, the Board has not overlooked the Veteran's contentions; his statements to healthcare providers; or his written statements. Here, as already alluded to, the claim is centered around the relationship between the Veteran's left knee and left hip disorders and his service-connected right knee disabilities. The Board is keenly aware that lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994) Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). 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. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The United States Court of Appeals for the Federal Circuit (Federal Circuit Court) also held in Buchanan (and Davidson and Jandreau), however, that the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. So to ultimately have probative value, the Veteran's assertions also have to be credible and judged in relation to the other evidence in the file - including any medical evidence addressing the determinative issue of causation. See Rucker v. Brown, 10 Vet. App. 67 (1997) and Layno, 6 Vet. App. at 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). However, the Board finds the Veteran's contentions as to the etiology of his claimed left knee and left hip disorders are of limited probative value under the circumstances. The medical issues in this case are fairly complex because they deal with degenerative joint disease, a musculoskeletal disorder that requires specialized training and equipment for a determination as to diagnosis and causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating and determining causal connections for such musculoskeletal disorders. King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. Although the Board recognizes the sincerity of the arguments advanced by the Veteran in this case, his contentions regarding the etiology of his claimed left knee and left hip disorders are not statements merely about symptomatology, an observable medical condition, or a contemporaneous medical diagnosis, but rather clearly fall within the realm of requiring medical expertise, which he simply does not have. That is to say, degenerative joint disease is not the type of condition that is readily amenable to mere lay diagnosis or probative comment on its etiology. The Board acknowledges the Veteran's competency as to the symptoms experienced and their possible etiological relationship to his service-connected right knee disability. However, whether there is actually any cause and effect relationship, and by this the Board means either that the right knee caused or aggravated his left knee and left hip problems, is not answered by his report of symptoms. Despite symptoms that often may be associated with an eventual diagnosis of degenerative joint disease, the Veteran is not in turn competent to ascribe these symptoms to a disorder related to a service-connected disability or military service. Therefore, the Veteran's opinion, to the extent it is to be accorded some probative value, is far outweighed by the findings of the examining and treating medical professional. See Jandreau supra & Buchanan supra. Accordingly, the preponderance of the evidence is against the claim and there is no reasonable doubt to be resolved. 38 U.S.C.A. § 5107(b). ORDER Service connection for a left knee disorder, to include as secondary to service-connected right knee disabilities is denied. Service connection for a left hip disorder, to include as secondary to service-connected right knee disabilities is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs