Citation Nr: 1333872 Decision Date: 10/25/13 Archive Date: 11/06/13 DOCKET NO. 05-04 255 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a total right knee replacement, including as secondary to a service-connected low back disability involving degenerative disc disease of the lumbar spine and associated left lower extremity radiculopathy with left foot drop. 2. Entitlement to service connection for a total left knee replacement, also including as secondary to this service-connected low back disability and associated radiculopathy of the left lower extremity with left foot drop. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from March 1953 to March 1956, in the U.S. Air Force from June 1956 to June 1960, and in the U.S. Navy from November 1960 to August 1974. This appeal to the Board of Veterans' Appeals (Board) is from a June 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In April 2011, the Board remanded these claims to the RO via the Appeals Management Center (AMC) for further development of the evidence, including for a VA examination for a medical nexus opinion regarding the etiology of these claimed knee disabilities. The Veteran had this requested VA examination in May 2011, and the examiner provided a medical opinion on the merits of this appeal at the conclusion of that evaluation, also later confirmed in a July 2011 addendum after reviewing the claims file for the relevant history. However, further comment from that examiner was needed before deciding these claims, so the Board again remanded these claims to the RO via the AMC in July 2012. In March 2013, the Board yet again remanded these claims to the RO via the AMC for still additional development of the medical evidence, as well as an attempt to locate service treatment records (STRs) that were apparently once part of the claims file. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. Please also note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) West 2002). FINDING OF FACT Neither the Veteran's right nor left knee disability was present during his service nor even for many ensuing years, and these disabilities have not otherwise been shown to be related or attributable to his service, including caused or permanently worsened by his service-connected low back disability and its associated complications. CONCLUSION OF LAW These claimed right and left knee disabilities were not incurred in or aggravated by his service, may not be presumed to have been, and are not secondarily related, either, meaning proximately due to, the result of, or aggravated by a service-connected disability - in particular, his low back disability and associated complications. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, (2013). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA and its implementing regulations impose obligations on VA to provide claimants with notice and assistance upon receipt of a complete or substantially complete application. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). To this end, VA must notify the claimant of the information or evidence that is necessary to substantiate the claim, including apprising him of what subset of the necessary information or evidence he is to provide versus that VA will attempt to obtain on his behalf. The so-called "fourth element" of the notice requirement requesting that he be apprised to provide any evidence in his possession pertaining to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353 -356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Court/CAVC) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim. Those five elements are: (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. So he should be apprised of all five of these elements, including the "downstream" disability rating and effective date elements. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). Ideally, this notice should be provided prior to an initial unfavorable decision on a claim by the RO as the Agency of Original Jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If, however, for whatever reason it was not or the notice provided was inadequate or incomplete, the issuance of a fully compliant VCAA notification followed by readjudication of the claim, including in a statement of the case (SOC) or supplemental SOC (SSOC), is sufficient to rectify ("cure") the timing defect in the provision of the notice. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). VCAA notices errors, even when shown to have occurred, are not presumptively prejudicial, rather, must be judged on a case-by-case basis. And as the pleading party attacking the agency's decision, the Veteran, not VA, has this burden of proof of not only establishing error, but, above and beyond that, showing how it is unduly prejudicial, meaning outcome determinative of the claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Here, in a timely January 2004 letter, the RO provided notice to the Veteran regarding what information and evidence was needed to substantiate a claim of entitlement to service connection, also of the information and evidence he needed to submit, and of the information or evidence VA would attempt to obtain for him. The notice did not include provisions for "downstream" disability ratings and effective dates in the eventuality the underlying claims for service connection are granted. But this additional notice was provided in July 2012 along with the requirements for establishing entitlement to secondary service connection. Moreover, the claims since have been readjudicated. See Prickett v. Nicholson, 20 Vet. App. 370, 376-78 (2006) (validating the remedial measures of issuing fully compliant VCAA notification and re-adjudicating the claim in the form of an SOC or SSOC to "cure" timing of notification defect). With regards to the duty to assist, the record contains no STRs. But as a practical matter, the Veteran is not prejudiced by their absence because the Board has found credible his assertions regarding multiple knee injuries in service. The record contains private treatment records and VA examination reports concerning his evaluation and treatment since service. When VA undertakes to provide a VA medical examination it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Here, in toto, the VA examinations provided were adequate. They took into account the history he provided, the other pertinent evidence of record, and the conclusions offered contained the necessary explanatory rationale, which, more than anything else, is where most of the probative value of an opinion is derived. Neives-Rodriguez v. Peake, 22 Vet. App. 295 (2008). For these reasons and bases, the Board finds that VA has fulfilled its duties to notify and assist the Veteran with these claims. Standard of Review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record, so both the relevant medical and lay evidence. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of a matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (reasonable doubt to be resolved in Veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a Veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Governing Statutes, Regulations, and Case Law Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If on the other hand a condition noted during service is not shown to be chronic, or this is legitimately questionable, then generally a showing of continuity of symptoms after service is required to support the claim. 38 C.F.R. § 3.303(b). Showing continuity of symptomatology since service under 38 C.F.R. § 3.303(b) is an alternative means of linking the currently-claimed disability to service, but is only available for the "chronic diseases" enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection nonetheless may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran currently has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a relationship or correlation between the disease or injury in service and the presently-claimed disability, which is the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Osteoarthritis will be presumed to have been incurred in service if manifested to a compensable degree of at least 10-percent disabling within one year after service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Service connection also may be granted on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Harder v. Brown, 5 Vet. App. 183, 187 (1993). In the case of aggravation, however, the Veteran is only compensated for the additional disability he has over and above that he had prior to the aggravation. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a correlation between the current disability and the service-connected disability either in the way of causation or aggravation. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). In deciding these claims, the Board must determine the probative value of all of the evidence submitted, so of both the lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine whether the evidence also is "credible", or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board additionally must determine whether the evidence also is credible). Only if the evidence is both competent and credible does it ultimately have probative value. See Layno v. Brown, 6 Vet. App. 465, 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")); Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). The third and final step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). A Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (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. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, a medical opinion was not required to prove nexus between service-connected mental disorder and drowning which caused Veteran's death). In certain instances, lay evidence has been found competent with regards to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). On the other hand, laypersons equally have been found not competent in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). See also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (indicating lay evidence must demonstrate some competence and affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). Competent medical evidence, as opposed to lay evidence, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. Competent medical evidence also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Generally, the degree of probative value that may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file, although this is not determinative of an opinion's probative value. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually had examined the Veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. 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). A physician's statement framed in terms such as "may" or "could" or "possible" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran). But see, too, Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). In deciding these claims, the Board has reviewed all of the evidence in the Veteran's claims file, both his physical claims file and electronic ("Virtual VA") file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by him or obtained on his behalf be discussed in exhaustive 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. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Discussion As already acknowledged, the STRs are unfortunately unavailable. Initially, the STRs from March 1953 to March 1956 were unavailable. However, during the course of this appeal, it appears that at least some medical records dated from June 1956 to August 1974 were available. Indeed, RO officials, VA examiners, and Board attorneys have cited them. Currently, however, even these STRs are unavailable. The Veteran has been advised of the situation. He was asked to submit any STRs in his possession. To date, he has not. He has posited two theories of how his knee disabilities are related to his military service. He claims: 1) that he injured his knees in the same incident as when he injured his low back in 1956, and 2) that the altered gait and neurological manifestations of this since service-connected low back disability caused or severely worsened, i.e., aggravated his knee conditions. In short, his claims are predicated on both direct and secondary service connection. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. And since, as will be explained, his knee disabilities and need for total knee replacements were because of osteoarthritis, the Board also must consider the notion of presumptive service connection. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). In deciding claims, the Board must consider all potential bases of entitlement, so, here, direct, presumptive and secondary service connection. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). VA has a duty to address all arguments put forth by a claimant and/or theories under which entitlement to benefits sought may be awarded. See Robinson v. Peake, 21 Vet. App. 545, 552 (2008) (noting that the Board is required to consider all issues raised either by the claimant or reasonably by the evidence of record), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009); Buckley v. West, 12 Vet. App. 76, 83 (1998) (noting that where the RO and the Board have failed to address an argument reasonably raised by a claimant in support of a claim over which the Court (CAVC) has jurisdiction by virtue of a Notice of Disagreement (NOD) satisfying Veterans Judicial Review Act (VJRA) § 402, the Court will remand the claim with directions that the Board address the particular argument(s) in support thereof). This includes the duty to address arguments a Veteran has specifically made as it relates to the adequacy of any given VA examination. From a review of the file, it appears the Veteran's STRs from June 1956 to August 1974 indicated that he had reported experiencing back pain in December 1956 after falling off a tank some time earlier. He now claims that he also injured his knees in that fall. Most of the VA examiners had an opportunity to review the STRs dated after his first period of active duty. All of those examiners emphasized that the STRs contained no evidence of treatment for the knees, despite the fact that the Veteran had received treatment on multiple occasions for injuries unrelated to the knees. These examiners also noted that he expressly had denied knee trouble on multiple reports of medical history completed during his service, to include prior to separation from his last period of active duty. Moreover, physical examination reports in service, including the report completed for separation purposes, indicated that his knees were normal. Written statements from him dated in more recent times reflect a history of multiple knee injuries in service, including the alleged bilateral knee injuries sustained when falling off a tank. But the contemporaneous medical records reveal only a back injury at that time, not also trauma involving his knees. Had he in fact sustained trauma to his knees when injuring his low back, it seems only reasonable that there would have been some mention of this, but there was not. Indeed, courts have recognized how medical history recounted in the course of medical evaluation and treatment is especially probative (trustworthy) because the declarant has inherent incentive to give the most accurate history to in turn receive the best or most appropriate medical care. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). When, as here, there is an inconsistently reported history - during service not claiming to have additionally injured the knees whereas now claiming to, even aside from the documented injury to the low back - this tends to undermine the probative value of this history, particularly to the extent the Veteran recounted it to any examiner or evaluating clinician who then, in turn, relies on this history as true and correct in formulating the basis of his or her opinion. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later); Struck v. Brown, 9 Vet. App. 145, 155-56 (1996) (Contemporaneous medical findings may be given more probative weight). Service connection is in effect for the residuals of that low back injury in service - specifically, for degenerative disc disease (DDD) of the lumbar spine. Service connection also has been established for the associated left lower extremity radiculopathy with left foot drop. The record reveals that arthritis of the knees was first officially diagnosed in 2000, so there is no indication he had this disease within one year of separating from service, certainly not to the minimally required compensable degree of at least 10-percent disabling. Arthritis must be objectively confirmed by X-ray. 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5003. In 2003, he had surgery for total knee replacements. X-rays taken just prior to those surgeries revealed bilateral three-compartment degenerative joint disease (DJD), i.e., arthritis, most severely affecting the medial compartment with extensive bone-on-bone contact and varus deformity. In January 2005, he submitted a written statement detailing several knee injuries over the course of his service. In March 2006, TRS, M.D. (pain management) indicated the Veteran was under his care for lumbar spondylosis with mixed back pain both mechanical and radicular. As well, Dr. TRS indicated the Veteran also had degenerative joint disease that had necessitated bilateral total knee replacements. Dr. TRS maintained that it was his "feeling" that these problems were related to the Veteran's initial injury while on active duty and are "certainly" entirely service connected. This opinion is not probative because it is not supported by rationale. Rather, it is "supported" by the physician's "feeling," which at the very least is unscientific and not based upon recognized medical principles. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (an adequate medical examination "must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions."). To reiterate, most of the probative value of an opinion comes from its underlying reasoning. As the Court made clear in Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008), the probative value of a medical opinion comes from when there is factually accurate, fully articulated, and sound reasoning for the conclusion, not just from mere review of the claims file. See also Dennis v. Nicholson, 21 Vet. App. 18, 22 (2007) ("The Court has long held that merely listing evidence before stating a conclusion does not constitute an adequate statement of reasons and bases." (citing Abernathy v. Principi, 3 Vet. App. 461, 465 (1992)). In February 2011, NM, M.D. opined that it was "possible" the Veteran's symptoms of osteoarthritis were due to his service. This opinion lacks probative weight because it is speculative or equivocal. See, e.g., Obert v. Brown, 5 Vet. App. 30 (1993); Tirpak v. Derwinski, 2 Vet. App. 609 (1992); Winsett v. West, 11 Vet. App. 420 (1998). In other words, saying something is "possible" necessarily also implies it "possibly is not." An etiological opinion, however, has to be viewed in its entire context and not characterized solely by the medical professional's choice of words. See Perman v. Brown, 5 Vet. App. 237, 241 (1993); Lee v. Brown, 10 Vet. App. 336, 338 (1997). Because of the looming uncertainty regarding the etiologies of the Veteran's right and left knee disabilities, especially the osteoarthritis that had prompted him to have the total knee replacement surgeries, he was afforded a VA medical examination for compensation purposes in May 2011. During the evaluation, the VA examiner noted the Veteran's then current complaints and then recent history regarding the total knee arthroplasty of each knee. The diagnosis reaffirmed there was DJD of the knees resulting in bilateral arthroplasty with moderate functional impairment. But concerning the etiology of this bilateral knee disability, the examiner indicated that, in his opinion, the Veteran's bilateral DJD of the knees resulting in arthroplasty was LESS LIKELY THAN NOT caused by, related to, or worsened beyond natural progression by his military service or service-related conditions (referring to the service-connected low back disability). This examiner therefore completely disassociated the Veteran's bilateral knee disability from his military service, both directly and secondarily by way of his service-connected low back disability. The examiner rationalized this opinion by indicating there was no record of treatment for knee impairment in the STRs. Indeed, according to this examiner, even when the events were documented, the medical records did not show injury of, or treatment for, the knees. He added that medical records included numerous military physical examinations, and self-reported medical histories. But none of these documented issues with the knees. He then recounted how the Veteran ultimately had knee replacement in 2003, 29 years after discharge from military service. And as, according to this examiner, DJD is a condition of aging, in his opinion, this was reason to disassociate this claimed bilateral knee disability from the Veteran's military service, either, as mentioned, directly or secondarily by way of the service-connected low back disability. That May 2011 VA examiner did not cite any medical authority or treatise to support his proposition that arthritis is only "a condition of aging", so not also in other instances a possible result of trauma/injury. And this was especially problematic since even VA's Rating Schedule recognizes arthritis as, at times, the result of trauma. See 38 C.F.R. § 4.71a, DC 5010 (indicating that arthritis due to trauma (i.e., post-traumatic arthritis), substantiated by X-ray findings, is to be rated as degenerative arthritis), which in turn is rated under DC 5003. The May 2011 VA examiner only cited an absence of recorded complaints and treatment in the Veteran's STRs referable to his knees, without also considering his contentions regarding his alleged injury to his knees in service. This, too, was problematic since in Dalton v. Nicholson, 21 Vet. App. 23 (2007), the Court had held that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury and instead relied on the absence of evidence in the Veteran's STRs to provide a negative opinion. Thus, to the extent that the May 2011 examiner's opinion was based upon a lack of evidence of injury or treatment of the knees in the STRs, it was inadequate for this reason as well. This required remanding these claims to obtain supplemental medical comment to correct these noted failings. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). In August 2012, the Veteran was afforded another VA examination. The examination report reveals that the examiner reviewed the record thoroughly. Indeed, the examiner summarized all of the pertinent evidence comprehensively. The examiner opined that the Veteran's bilateral knee osteoarthritis was unrelated to service and provided a number of reasons for his rationale. First, the examiner explained that there was an absence of complaints or treatment for the knees in the STRs, despite the fact that many other injuries unrelated to the knees were documented in the STRs. The examiner also pointed to the medical history recounted by the Veteran. Apparently he reported that, after sustaining knee injuries in 1954, X-rays of the knees were taken, and he was told his knees would return to normal in a few days' time. According to the examiner, this history indicated the alleged injury in service was not significant as it was expected to soon resolve. The examiner also indicated that private medical records were silent as to the knees until 2000. Also, the examiner noted that the knee symptoms reported by the Veteran could not be corroborated because there was no documentation of knee complaints in service or for more than two decades following active duty and that during this time period other injuries were reported and treated. Further, the examiner noted that the Veteran had other risk factors for osteoarthritis, namely age and obesity. Finally, the examiner stated there were two post-service falls in 1998. As to Dr. TRS's 2006 statement, the August 2012 VA examiner stated that the facts upon which Dr. TRS had based his opinion regarding the etiology of the Veteran's knee disabilities were unclear. Thus, he could not comment intelligently upon the validity of Dr. TRS's opinion. In a December 2012 addendum, the VA examiner explained that risk factors for osteoarthritis included "repetitive, small insults over time", yet the August 2012 opinion did not appear to recognize the Veteran's reports of multiple small knee injuries during his military service by hitting steel "knee knockers.". See the Veteran's January 2005 statement. Because the examiner did not take into account the Veteran's reports of multiple knee injuries in service, the December 2012 addendum was inadequate also. See Reonal, 5 Vet. App. at 461 (medical opinion based upon an inaccurate factual premise has no probative value). In December 2012, the examiner opined that the Veteran's bilateral knee disabilities were not the result of or aggravated beyond their natural progression by the service-connected low back disability. The examiner explained that there was no clear basis in the medical literature of limping causing or aggravating osteoarthritis in the opposite extremity. As well, he explained that the causation in osteoarthritis was complex and multifactorial and there was no indication that a disability in the low back could cause or aggravate osteoarthritis in the knees. This opinion is fully reasoned, and the Board, therefore, finds that it carries much probative weight. See Prejean, supra. In May 2013, the VA examiner reviewed the available records yet again. In response to the March 2013 Board remand question "[e]xplain the basis for concluding that the 2 falls that occurred in 1998 involved injury to the Veteran's knees, specifically, rather than say just to his hips", the VA examiner responded that the two falls that had occurred in 1998 are less likely as not caused by or a result of his hips because the onset of back pain centered in left hip (reported on 5/11/98) was 4 days prior, and the two falls were two weeks prior, and because there is no documentation of any hip pathology as of 5/11/98 or within a reasonable time after that, whereas there is documentation of "long time" existence of arthritis of knees with inability to walk without a cane and stiffness in knees with weather changes, on 1/11/00. The preponderance of medical evidence does not support aggravation of falls by the back pain centered in left hip. Further in response to the Board's March 2013 remand question "[e]xplain why the Veteran's reports of multiple minor bilateral knee injuries is not a risk factor when minor injuries of this nature would not necessarily be reported", the May 2013 VA examiner responded that the reports of multiple minor bilateral knee injuries (when minor injuries of this nature would not necessarily be reported) are less likely to cause or result in or be risk factors for the Veteran's osteoarthritis of knees because STRs and two year post service (and beyond) medical records are silent for clinical or radiological findings consistent with osteoarthritis of knees, until 1/11/00 (>25 years after service). The May 2013 opinion, itself a supplement of a supplement, is fully reasoned and based on a review of the evidence of record. As such, the Board accords it great probative weight. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir, 1997) (holding that the Board has a duty to assess the credibility and weight to be given to the evidence). The Board does not dispute the Veteran's assertions regarding multiple knee injuries in service. Nonetheless, the Board cannot rely on these representations and the Veteran's apparent assertions that those traumas caused his subsequent osteoarthritis of the knees because, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the origins of osteoarthritis fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Board finds that a chronic bilateral knee disability was not incurred in service. While the Veteran may well have sustained knee injuries during his service, as he alleges, they were, according to the June 2013 VA examiner, apparently relatively minor and not productive of any lasting or permanent disability. The Veteran expressly denied any disability or impairment involving his knees during his service, including at time of separation, and examiners, including the one that evaluated him for separation from service, found that his knees did not have any impairment or disability. All of this tends to refute the notion that his bilateral knee disability was incurred during his service. 38 C.F.R. § 3.303(a). The Board further finds that a disability of the knees was not present within the first post-service year, so resultantly cannot be presumed to have been incurred in service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). No disability of the knees was noted on separation from the Veteran's last period of service and no complaints or diagnoses pertaining to the knees were recorded until 2000, thus, not until many years later, long after his separation from service. Similarly, the Board finds that service connection for the bilateral knee disability is not warranted based on continuity of symptomatology. 38 C.F.R. § 3.303(b). Again, there is complete silence in the record regarding the knees after service until 2000, at the earliest. Such a substantial lapse in time between service and the first diagnosis of osteoarthritis of the knees tends to weigh against the Veteran's claims. In Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) recognized lay evidence as potentially competent to support the presence of the claimed disability, both during service and since, even where not corroborated by contemporaneous medical evidence such as actual treatment records. The Federal Circuit Court went on to indicate in Buchanan, however, that the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan, 451 F.3d at 1336 ("Nor do we hold that the Board cannot weigh the absence of contemporaneous medical evidence against the lay evidence of record"). Moreover, although the Board cannot reject a claimant's statements merely because he is an interested party, the claimant's interest may affect the credibility of his testimony when considered in light of the other factors. See Cartright, 2 Vet. App. at 25; accord Buchanan, 451 F.3d at 1337 (holding that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias . . . ."). The Federal Circuit Court has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Board therefore may consider the absence of any indication of a relevant medical complaint until so relatively long after service as one factor, just not the only or sole factor, in determining whether a disease or an injury in service resulted in chronic or persistent residual disability. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). See, too, Mense v. Derwinski, 1 Vet. App. 354 (1991) (holding that VA did not err in denying service connection when the Veteran had failed to provide evidence demonstrating continuity of symptomatology and had failed to account for the lengthy time period following service during which there was no clinical documentation of the claimed disorder). That said, as held in Kahana and Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc), negative evidence, meaning actual evidence weighing against a party, must not be equated with the absence of substantive evidence. Ultimately, the Board must consider all the evidence relevant to the claims, including the availability of medical records, the nature and course of the disease or disability, the amount of time that has elapsed since military service, and any other pertinent facts. Cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact-finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). The Board finds that the Veteran's bilateral knee disability is not otherwise related or attributable to his service. 38 C.F.R. § 3.303(d). The VA examiners have cited his many risk factors for osteoarthritis include his age and obesity, and while trauma could be a cause, the June 2013 VA examiner found that, in this particular Veteran's case, trauma to the knees in service (so even accepting it occurred as alleged) was not a factor in the Veteran developing these knee disabilities. Again, therefore, the Board finds that these claimed knee disabilities are unrelated to his service. Id. There is not the required attribution of this disability to his service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). The Board next finds that the most competent and credible, so ultimately probative, evidence shows that the service-connected low back disability did not alternatively cause or aggravate beyond its natural progression the Veteran's bilateral knee osteoarthritis. The June 2013 VA examiner explained in detail why there was no cause-and-effect correlation or relationship between the service-connected disability of the low back and the bilateral knee osteoarthritis. As such, service connection for the bilateral knee disability also is not warranted on a secondary basis, to include on the basis of aggravation. 38 C.F.R. § 3.310(a) and (b); Allen supra. For these reasons and bases discussed, the Board finds that the preponderance of the evidence is against these claims of entitlement to service connection for osteoarthritis of the knees, including as secondary to the service-connected low back disability and associated complications. Because the preponderance of the evidence is against these claims, the benefit-of-the-doubt doctrine is inapplicable. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Accordingly, these claims must be denied rather than granted. ORDER The claims of entitlement to service connection for total right and left knee replacements, including as secondary to the service-connected low back disability involving DDD of the lumbar spine and associated left lower extremity radiculopathy with left foot drop, are denied. ______________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs