Citation Nr: 1333394 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 02-21 675 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to service connection for a right knee disability, to include as secondary to service-connected residuals of a torn medial meniscus in the left knee. 2. Entitlement to service connection for a lumbar spine disability, to include as secondary to service-connected residuals of a torn medial meniscus in the left knee. 3. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jeanne Schlegel, Counsel INTRODUCTION The Veteran served on active duty from October 1970 to June 1973. This appeal to the Board of Veterans' Appeals (Board) arose from RO rating decisions dated in March 2004, and March 2006. In a March 2004 rating decision, the RO denied service connection for a right knee disability and a lumbar spine disability, as well as denied a rating in excess of 10 percent for residuals of a torn medial meniscus in the left knee. In April 2004, the Veteran filed an NOD. An SOC was issued in April 2004, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in May 2004. In a March 2006 rating decision, the RO, inter alia, denied service connection for tinnitus. In April 2006, the Veteran filed an NOD. An SOC was issued in June 2006, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in July 2006. In February 2007, the Veteran testified during a Board hearing before a Veterans Law Judge at the RO; a transcript of that hearing is of record. During the hearing, the Veteran submitted additional evidence, along with a signed waiver of RO jurisdiction. See 38 C.F.R. §§ 20.800, 20.1304 (2013). The Veterans Law Judge who presided over the 2007 Board hearing is no longer employed at the Board. The law requires the Veterans Law Judge who conducted the hearing to participate in the decision on appeal. 38 C.F.R. § 20.707 (2013). Therefore, in July 2012, the Board sent the Veteran a letter informing him of this and offering him another hearing before a Veterans Law Judge that will ultimately decide this appeal. However, the Veteran indicated in his August 2012 response that he did not wish to have another hearing. In January 2008, the Board remanded the claims on appeal to the RO, via the Appeals Management Center (AMC) in Washington, DC, for further action, to include additional development of the evidence. The case came before the Board again in October 2012, at which time service connection claims for disabilities of the right knee and lumbar spine, and for tinnitus for further action, to include additional development of the evidence. As will be explained herein, there was substantial development with respect to the service connection claims for disabilities of the right knee and lumbar spine and they are ready for appellate consideration. The service connection claim for tinnitus requires additional action on Remand as will be further explained herein. Also addressed by the Board in October 2012, as an issue in appellate status was the matter of entitlement to a separate, compensable rating for osteoarthritis of the left knee. That claim was granted in a September 2013 rating action and is no longer in appellate status. The Board also notes that, in addition to the paper claims file, there is an electronic (Virtual VA) file associated with the Veteran's claim. An October 2013 review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. The Board's decision addressing the service connection claims for right knee and low back disabilities is set forth below. The service connection claim for tinnitus is addressed in the remand following the order; those matters are being remanded to the RO, via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant when further action, on his part, is required. As a final preliminary matter, the Board notes that the issue of entitlement to a rating in excess of 10 percent for left knee osteoarthritis has been raised by the record (see September 2013 document), but has not been adjudicated by the RO. Therefore, the Board does not have jurisdiction over this matter, and it is referred to the RO for appropriate action. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim herein decided have been accomplished. 2. A right knee disability was not manifested during service or during the first post-service year; and no such current disability is shown or contended to be causally or etiologically related to service. 3. The preponderance of the evidence of record is against a finding that the Veteran's right knee condition was caused, aggravated by, or otherwise related to, any service-connected disorder. 4. Disability of the lumbar spine was not manifested during service or during the first post-service year; and no such current disability is shown or contended to be causally or etiologically related to service. 5. The preponderance of the evidence of record is against a finding that a condition of the lumbar spine was caused, aggravated by, or otherwise related to, any service-connected disorder. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee disability, to include on a secondary basis, are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 2. The criteria for service connection for a lumbar spine disability, to include on a secondary basis, are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2013)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 was revised, in part. See 73 Fed. Reg. 23,353-23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's 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/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, in a January 2004 pre-rating letter, the RO provided notice to the Veteran regarding what information and evidence was needed to substantiate his service connection claim for right knee and low back conditions. This letter also informed the Veteran of what information and evidence must be submitted by the appellant and what information and evidence would be obtained by VA. A later March 2006 letter, issued after the March 2004 rating action on appeal, also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Thereafter, the RO adjudicated the claims in Supplemental SOCs issued in April 2006, November 2010, May 2012, and September 2013. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of fully compliant notification followed by readjudication of the claim, such as an Statement of the Case or Supplemental Statement of the Case, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the claims herein decided. On file are the Veteran's service treatment records (STRs), pertinent private and VA medical records, Board hearing testimony presented in 2007, and various written statements by the Veteran and his representative, on his behalf. The Board finds that no further RO action, prior to appellate consideration, is required. The file also contains numerous medical examinations and opinions provided from 2004 forward. The Board finds that no further RO action on these matters, prior to appellate consideration, is required. Pursuant to a Board Remand of October 2012, addendum VA examination/opinions were ordered. The record reflects that a VA examination with the requested opinions was provided in April 2013. The evidence on file adequately addresses the matters related to the claims on appeal, and neither the Veteran nor his representative has maintained that any examination report on file or opinion provided is inadequate for purposes of adjudicating the claims on appeal. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011), (in the absence of a challenge to the adequacy of the examination, the Board is not required to explicitly explain why each medical opinion is adequate). In addition, it appears that there has been substantial compliance with the October 2012 Board remand directives, and the case has returned to the Board for appellate consideration. See also D'Aries v. Peake, 22 Vet. App. 97 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board's remand directives is required). In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO, the Veteran has been notified and made aware of the evidence needed to substantiate these claims, the avenues through which he might obtain evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with either claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Service Connection Claims Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). 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). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection shall be granted to a Veteran if the Veteran served 90 days or more during a war period or after December 31, 1946 or had peacetime service on or after January 1, 1947, and conditions including arthritis, although not otherwise established as incurred in or aggravated by service, are manifested to a compensable degree within one year following the requisite service. 38 C.F.R. §§ 3.307, 3.309 (2013). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2013). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc), reconciling, Leopoldo v. Brown, 4 Vet. App. 216 (1993), and Tobin v. Derwinski, 2 Vet. App. 34 (1991). The Board must assess the credibility and weight of all the 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 claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2013). The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). A. Background As the history, background, and analysis, relating to the two claims on appeal are substantially similar, for purposes of this case they are being presented together. In October 2003, the Veteran filed service connection claims for right knee and back conditions, both claimed as secondary to a service-connected left knee disability. Service connection was established for a torn medial meniscus of the left knee in an October 1973 rating action. The STRs include an August 1970 enlistment examination report which reflects that clinical evaluation of the spine and lower extremities was normal. In November 1972, the Veteran was involved in a motorcycle accident, resulting in diagnoses of left torn medial meniscus, and chondromalacia of the left patella; no other injuries were diagnosed in conjunction with the accident. In January 1973, the Veteran was treated for mid to upper back pain and strain. Physical and Medical Evaluation Boards Reports of 1973 reflect that the Veteran was determined to be unfit for duty due to his left knee disability (only), for which he was ultimately discharged. There is no indication that a separation examination was conducted. VA records include entries dated from 2002 to 2004 documenting numerous trips made by the Veteran (some to the emergency room) related to complaints of knee and/or back symptoms. A July 2002 record notes a history of a left knee injury 2 months previously. In September 2003, the Veteran complained of a 3 month history of tight knee and low back pain, worsening. Right knee X-ray films taken in September 2003 revealed large joint effusion and no fractures or dislocations. X-ray films of the lumbar spine also taken in September 2003 showed posterior fusion of L4-S1, narrowed L3-5 disks, and no evidence of fractures or compressions. A February 2004 entry states that the Veteran had noticed symptoms of bilateral knee pain for the past year, assessed as knee pain/arthralgia. A VA examination of the joints was conducted in January 2004. The Veteran reported that he has worked for the postal service for 20 years, and for many years used to carry a walking mail route, but now had a truck route. A history of left knee injury and current symptoms of pain, swelling and giving way was noted. On examination, gait was even, and the Veteran did not use any ambulatory aids. The Veteran gave a history of right knee pain beginning the year previously, accompanied by symptoms of swelling. Examination revealed right knee tenderness, without effusion or instability. There was no clinical diagnosis made and the examiner commented that the there was significant resistance to the entire examination and magnification of symptoms. Benign appearance and examination of the eight knee was assessed. The report also notes a history of a back pain which started with a lifting injury while working at the post office, following which the Veteran underwent lumbar spine decompression and fusion in 1987. An assessment of lumbar spine, status post L4 to S1 fusion with decompression was made. Recurrent low back pain and degenerative changes were also noted. The examiner again mentioned magnification of symptoms. The examiner opined that problems with the right knee and lumbar spine were not related to the service-connected left knee disability. It was explained that the lumbar spine problem was directly related to an injury sustained on the job with the postal service with associated surgery. The examiner also opined that there was no evidence that the right knee was overstressed because gait was normal, and stated that the Veteran's right pain was a problem of aging and attrition. The file contains a January 2005 private medical report of Dr. R.M.R., indicating that the Veteran was seen on referral due to bilateral knee pain. A history of left knee injury in 1973 was noted and the doctor indicated review of the Veteran's medical history and chart. X-ray films revealed early degenerative joint disease of the right knee. Severe left knee osteoarthritis was also assessed. When seen later in January 2005, the Veteran complained that his left hip and low back were also symptomatic and he felt like this was because of the way he was walking, secondary to his knee symptoms. The doctor opined that this was very likely, as arthritis in the knee was probably changing his gait, irritating the left hip and back. Bilateral knee pain, secondary to osteoarthritis, worse on the left was assessed. On VA examination of the spine conducted in June 2005, degenerative disc disease of the lumbar spine with back pain was diagnosed. In February 2007, the Veteran presented testimony at a travel Board hearing. The Veteran stated that his right knee swelled a lot because he was trying to take pressure off of his left knee. The transcript also reflects that the Veteran hurt his back at work, but that this condition reportedly continually became worse because of weight shifting associated with knee problems. A VA examination of the spine and joints was conducted in August 2010 and the claims file was reviewed. A history of a left knee injury due to a motorcycle accident in the early 1970's was noted. The Veteran indicated that since then, he has been limping and as a result of compensating for the left knee, he has developed right knee arthritis and low back pain. Diagnoses of osteoarthritis of the lumbar spine, right knee, and left knee were made. The examiner opined that the right knee and lumbar spine conditions were not connected to the left knee disability. It was noted that a review of orthopedic literature revealed no peer reviewed studies that support the theory that post-traumatic degenerative changes of a joint may induce degenerative changes in the spine at any level. The examiner concluded that it was more likely the Veteran's joint conditions were related to chronic degenerative changes as a result of aging, musculoskeletal deconditioning due to physical activity, and a genetic predisposition to developing osteoarthritis of the spine and knees. In an amended opinion provided in November 2010, one of the examiners who conducted the August 2010 examination clarified that it was less likely as not that the right knee condition was caused or aggravated by the service-connected left knee disability. It was noted that a review of orthopedic literature revealed no peer reviewed studies that support the theory that post-traumatic degenerative changes of a joint may induce degenerative changes in the spine or a contralateral joint at any level. The remainder of the reasoning was the same as that recorded above. Another VA examination was conducted in April 2011. The Veteran complained of pain generalized in the left knee, and 15 to 20 year history of right knee pain without injury. He also reported a 30 year history of problems with the lumbar spine, and a work related in 1986 or 1987, for which surgery was required and a Worker's Compensation claim was filed. Gait was slow and guarded on examination, but it was not antalgic. Right knee degenerative joint disease with myofascial pain was diagnosed as was lumbar degenerative disc disease. The examiner observed that with regard to the Veteran's contentions that right knee and lumbar spine conditions were caused by/the result of a left knee disability, he knew of no medical authority or medical literature which supports the contention that right knee right degenerative joint disease can be caused by or the result of a left knee injury. It was pointed out that the Veteran had a non-antalgic gait to support this contention. With respect to the condition of the lumbar spine, the examiner mentioned that the Veteran had a work-related injury post-service while led to surgery. The examiner explained that the progression of the condition of the lumbar spine since surgery was not unanticipated and would be in the absence of any left knee condition. An addendum to the April 2011 VA opinion was provided by the examiner in May 2011, following and based upon review of the claims folder. Diagnoses of right knee degenerative joint disease with myofascial pain, and lumbar degenerative disc disease with bilateral radiculopathy and chronic myofascial pain were made and the examiner clarified that in both cases, the conditions were less likely as not to have been caused by and the result of military service. Upon review, the examiner noted that the medical evaluation board (MEB) was based entirely on the left knee injury; no mention was made with regard to the lumbar back or right knee. It was also mentioned that STRs reflected that the Veteran was seen in January 1973 with regard to a back injury, described in the initial note as a mid thoracic soft tissue injury, and not relating to the lumbar back. The examiner observed that no mention was made of this in the MEB, and it is presumed to have resolved prior to discharge. No other additions or correction to the April 2011 opinions were made. Pursuant to an October 2012 Board Remand, still more VA opinions were sought in conjunction with the Veteran's claims. In February 2013, the VA examiner who had provided opinions in 2011 indicated review of the claims file in its entirety. A diagnosis of right knee degenerative joint disease with myofascial pain was recorded and the examiner opined that it was less likely as not that the right knee condition was caused by, aggravated by, or the result of a service connected left knee condition. The examiner noted gait was normal on examination and explained that he knew of no medical authority or peer reviewed medical literature that support the theory that a left knee meniscal tear with degenerative joint disease could e causative of or aggravating the development of contralateral knee degenerative disease. The examiner added that the Veteran's right knee degenerative joint disease was the result of a lifetime of chronic weight bearing on the right knee, unrelated to the service-connected left knee disability. The February 2013 VA opinion also reflects that a diagnosis of lumbar degenerative disease was recorded and the examiner opined that it was less likely as not that this condition was caused by, aggravated by, or the result of a service connected left knee condition. The examiner noted gait was normal on examination and explained that he knew of no medical authority or peer reviewed medical literature that supported the theory that a lumbar degenerative disease could be caused or aggravated by a left knee meniscal tear with degenerative joint disease. The examiner lumbar degenerative disease was a disease or life, caused by chronic weight bearing on the lumbar disc mechanism. It was explained that this process was documented in most individuals over age 50, regardless of other lower extremity conditions. In April 2013, a VA examination was conducted and the claims file was reviewed. Osteoarthritis of the right knee was diagnosed. The examiner opined that this condition was less likely than not proximately due to or the result of the service-connected knee disability. The examiner explained that it was more likely than not that the right knee condition was due to chronic degenerative changes associated with aging. Lumbar degenerative disc disease without clinical signs of lumbar radiculopathy was also diagnosed. The examiner opined that this condition was less likely than not proximately due to or the result of the service-connected left knee disability, as no credible studies had found that degenerative changes in one joint may induce degenerative changes in another joint. B. Analysis The Veteran maintains that service connection is warranted for both right knee and lumbar spine conditions, secondary to a service-connected left knee disability, by virtue of causation or aggravation. He has not contended and the evidence does not establish or even suggest that either condition had its onset during service or within the first post-service year, or that either is otherwise etiologically related to his period of service. Where neither the Veteran nor the record raises the theory of entitlement to service connection on a direct basis, the Board need not sua sponte consider and discuss that theory. Therefore, the theory of direct service connection will be only briefly addressed herein, for the sake of completeness. Robinson v. Mansfield, 21 Vet. App. 545 (2008). Service connection on a secondary basis requires (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Indisputably, the record contains medical evidence of the currently claimed conditions, which have been primarily diagnosed as osteoarthritis of the right knee and lumbar degenerative disc disease. The remaining question is whether or not currently either claimed condition was incurred during or as a result of the Veteran's active military service, presumptively or otherwise, or is secondarily related to a service-connected disorder by virtue of causation or aggravation. The STRs are silent for any indication of injury, treatment or diagnosis relating to the right knee or lumbar spine. The Veteran was seen in January 1973 relating to a back injury, described as a mid thoracic condition; such injury was not in the lumbar area. Accordingly, the STRs are negative for the incurrence of any right knee or low back injury, symptomatology, or diagnosis, a fact that weighs heavily against the claim based on the theory of direct service incurrence, such that the claim may be denied on the basis of lack of evidence of service incurrence. The record also fails to show that arthritis of the right knee or low back manifested to a degree of 10 percent by June 1974 (within the first year following his active duty service discharge, in June 1973), nor does the Veteran specifically maintain that it manifested during this time frame. A chronic disease need not be diagnosed during the presumptive period under 38 C.F.R. § 3.307(c), but if not, there must then be shown by acceptable medical or lay evidence, characteristic manifestations of the disease to the required degree, followed without unreasonable time lapse by definite diagnosis. Caldwell v. Derwinski, 1 Vet. App. 466, 469 (1991). No such evidence has been presented in this case; accordingly, service connection on a presumptive basis is not established under 38 C.F.R. §§ 3.307, 3.309. The Veteran maintains that both right knee and lumbar spine conditions are secondary, by virtue of causation or aggravation, to a service-connected left knee disability. In this case, the file contains no less than 7 VA opinions/addendums indicating that both conditions of the right knee and lumbar spine were less likely than not caused or aggravated by a service-connected left knee disability. Among the 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. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The reasons supporting those opinions are detailed above and reflect review of the lay and clinical history of both the claimed conditions and the service-connected condition, the treatment and progression of both, and review of medical literature. Therefore, Board finds no adequate basis to reject any of the competent medical opinions provided by VA for the record based on a lack of credibility or probative value, and finds the opinions to be of significant probative value. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). ). In addition, the Veteran has not provided any competent evidence to rebut these opinions or otherwise diminish their probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). By contrast, the file contains one medical report with opinions provided in January 2005 by Dr. R.M.R. At that time, the Veteran complained that his left hip and low back were symptomatic and he felt like this was because of the way he was walking, secondary to his knee symptoms. The doctor opined that this was very likely, as arthritis in the knee was probably changing his gait, irritating the left hip and back. Bilateral knee pain, secondary to osteoarthritis, worse on the left was assessed. As an initial matter, the doctor does not actually secondarily link, either by causation or aggravation, the claimed right knee condition to the service-connected left knee disability. Right knee pain was generally linked to diagnosed osteoarthritis, affecting both knees, without specific reference to left knee osteoarthritis as the cause of pain. To the extent that the private opinion of January 2005 represents evidence favorable to the Veteran's claims, particularly relating to the low back, it lacks the probative value of the aforementioned VA opinions as it is both speculative and based on incomplete medical information. Significantly, the fact that the Veteran sustained a serious post-service industrial back injury in 1986 or 1987 requiring surgery does not appear to be accounted for in conjunction with the doctor's opinions. Moreover, the use of the word "probably" renders the opinion speculative. Medical evidence that is speculative, general, or inconclusive in nature, such as the 2012 VA opinion, cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). To the extent that the Veteran himself asserts he suffers from conditions of the right knee and lumbar spine as a result of a service-connected condition, the Board does not question the Veteran's sincerity in his belief that his currently claimed conditions are etiologically related to such a cause. 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, providing an opinion as to the etiology of hypertension falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." Accordingly, the Veteran's opinions in this regard are not competent, are therefore are of no probative value in this case. The Board finds that the preponderance of the evidence is against the Veteran's claims for service connection for right knee and lumbar spine disabilities, to include on a secondary basis, and that, therefore, each claim must be denied. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). ORDER Service connection for a right knee disability, to include on a secondary basis, is denied. Service connection for a low back disability, to include on a secondary basis, is denied. REMAND Unfortunately the Board finds that further RO action on the matter remaining on appeal is warranted, even though such will, regrettably, further delay an appellate decision on this matter. A remand by the Board confers upon on an appellant, as a matter of law, the right to compliance with the terms of the remand order and imposes upon VA a concomitant duty to ensure compliance with those terms. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In the instant case, in the October 2012 remand, the Board requested that the Veteran's entire claims file, to include a complete copy of the REMAND, be forwarded to the physician who examined the Veteran in August 2010 (Dr. J.S.K.), for an addendum opinion. Based on review of the claims file, the physician was asked to provide an opinion, consistent with sound medical principles, as to whether it at least as likely as not (i.e., there is a 50 percent or greater probability) that the tinnitus had its onset in or is otherwise medically related to service, to specifically include alleged injury therein. The Board specified that if the prior examiner was not available, or further examination of the Veteran was deemed warranted, the RO should arrange for the Veteran to undergo a VA ENT examination, by an appropriate physician, at a VA medical facility, to obtain a medical opinion addressing the question posed above. In rendering the requested opinion, the physician was specifically requested to consider and discuss the service treatment records, and the August 2010 VA examination report and October 2010 VA addendum opinion, along with all other post-service medical evidence, and the Veteran's contentions. In an opinion offered provided in August 2013 it was noted that a review of the claims file was completed, revealing normal audiological findings on enlistment in 1970; absence of complaints, treatment or a diagnosis of tinnitus in service, and no separation audiogram. The examining audiologist concluded that the cited evidence did not show findings related to tinnitus and that therefore it was less likely that tinnitus was related to noise exposure during service. Upon review, it is clear that the audiologist issuing the 2013 opinion, did not consider and discuss evidence specified in the 2012 Board Remand, to include the August 2010 VA examination report and October 2010 VA addendum opinion, as well as the Veteran's lay contentions. Further with respect to the rationale supporting the VA opinion provided in 2013; namely that the STRs were negative for complaints, treatment or a diagnosis of tinnitus in service, the Court has held that silence in the service treatment records can constitute "contradictory" evidence weighing against the credibility of a claimant's testimony. Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring). However, in order to infer from this silence that a claimed disability did not manifest during active service, the Board must find that the service treatment records are complete "in relevant part," and that the claimed "injury, disease, or related symptoms would ordinarily have been recorded had they occurred." Id. (citing Fed.R.Evid. 803 (7) (the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded)). Here, there was no separation examination conducted and as such, it is not clear that a valid basis for the opinion was provided, raising a question of whether the 2013 VA opinion was adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (stating that an adequate VA examination must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions). VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for determining whether the evidence 'indicates' that there 'may' be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon, 20 Vet. App. at 83. Furthermore, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Thus, remand is required to ensure compliance with the Board's October 2012 remand. See Stegall, 11 Vet. App. at 271. Hence, given the deficiencies discussed above, the RO should forward the claims file to the audiologist who provided the August 2013 examination for an addendum opinion to provide a clearly-stated rationale addressing the matter of whether the Veteran's claimed tinnitus is at least as likely as not related to noise exposure in service, or otherwise etiologically related to service, as contended, specifically addressing evidence of record, including the Veteran's lay statements indicating that the onset of his tinnitus, the STRs and nature of the Veteran's MOS and primary service functions; the August 2010 VA examination report and the October 2010 VA addendum opinion. The RO should only arrange for the Veteran to undergo VA examination by an ear nose and throat (ENT) physician (preferably) or audiologist if the August 2013 examiner is not available, or another examination of the Veteran is deemed warranted. The Veteran is hereby notified that failure to report to any scheduled examination, without good cause, may result in denial of the claim(s) for service connection (as the original claim will be considered on the basis of the evidence of record). See 38 C.F.R. § 3.655 (2013). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. If the Veteran fails to report to any scheduled examination, the RO should obtain and associate with the claims file (a) copy(ies) of the notice(s) of the date and time of the examination sent to him by the pertinent VA medical facility. Prior to obtaining a further medical opinion in connection with this claim, to ensure that all due process requirements are met, and that the record before each examiner is complete, the RO should undertake action to obtain and associate with the claims file all outstanding, pertinent records. As for VA records, the paper claims file as well as the Virtual VA electronic record currently include outpatient treatment records from the VA Texas HCS dated through May 2012; however, more recent records from this facility may exist. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Hence, the RO must obtain all outstanding pertinent VA treatment records from June 2012, forward, following the current procedures prescribed in 38 C.F.R. § 3.159 with respect to requesting records from Federal facilities. The RO should also give the Veteran another opportunity to present information and/or evidence pertinent to the claims for service connection. The RO's letter to the Veteran should explain that he has a full one-year period for response. See 38 U.S.C.A § 5103(b)(1) (West 2002); but see 38 U.S.C.A. § 5103(b)(3) (West Supp. 2012) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). Thereafter, the RO should attempt to obtain any additional evidence for which the appellant provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the VCAA. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2013). However, identification of specific actions requested on remand does not relieve the RO of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the RO should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claims on appeal. Accordingly, these matters are hereby REMANDED for the following action: 1. Obtain from the Texas VA HCS all outstanding, pertinent records of evaluation and/or treatment of the Veteran, dated from June 2012, forward. The RO must follow the procedures set forth in 38 C.F.R. § 3.159(c) as regards requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization to obtain any additional evidence pertinent to the claims on appeal that is not currently of record. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 3. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After all records and/or responses received are associated with the claims file, forward the entire claims file, to include a complete copy of this REMAND, to the same audiologist who provided the August 2013 opinion, in order to obtain an adequate opinion with complete rationale addressing whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the Veteran's tinnitus was caused by or is a result of military noise exposure, or is otherwise etiologically related to service. (a) In providing this rationale, the audiologist should specifically consider and discuss: the service treatment records, which include a reference to tinnitus in a 1992 record; the August 2010 VA examination report and October 2010 VA addendum opinion; the Veteran's assertions that the onset of his tinnitus was during service, continuing thereafter, pertinent lay reports; as well a other pertinent post-service medical evidence such as VA records. In providing an adequate basis for an opinion, the evaluator is notified that the absence of indications of tinnitus on separation is not valid reasoning in this case, as there is no separation examination in the service treatment records. (b) If the prior examiner is not available, or further examination of the Veteran is deemed warranted, the RO should arrange for the Veteran to undergo examination, by an appropriate Ear, Nose and Throat (ENT) physician, preferably, or audiologist at a VA medical facility, to obtain a medical opinion addressing the question posed above. In this event, the entire claims file, to include a complete copy of the REMAND, must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented medical history and assertions. All appropriate tests and studies should be accomplished (with all results made available to the examining physician prior to the completion of his or her report), and all clinical findings should be reported in detail. In rendering the requested opinion, the examiner should specifically consider and discuss the information as provided in paragraph (a) above. (c) In the event of either (a) and (b), the clinician should set forth the opinion, along with complete rationale for the conclusions reached, in a printed (typewritten) report. 5. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 6. After completing the requested actions, and any additional notification and/or development deemed warranted, readjudicate the matter remaining on appeal in light of pertinent evidence (to particularly include all that added to the record since the RO's last adjudication of the claim), and legal authority. 7. If any benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate SSOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefits requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs