Citation Nr: 1334323 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 07-32 832 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a left knee disorder. 2. Entitlement to service connection for a low back disorder, on a direct basis and as secondary to a service-connected disability. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1962 to September 1964 and from January to March 1991, plus service in the Army Reserve. This appeal comes to the Board of Veterans' Appeals (Board) from a November 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey, and a December 2006 rating decision by the VA RO in Togus, Maine. The location of the Veteran's residence has changed during the pendency of the appeal and is now under the jurisdiction of the Winston-Salem, North Carolina, RO. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in January 2008. A transcript of the hearing is of record. Subsequently, in August 2008, the Board remanded the case to the RO for further development. In reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the Virtual VA and VBMS system to insure a total review of the evidence. FINDINGS OF FACT 1. The Veteran injured his left knee in service and was diagnosed with left knee sprain. 2. Symptoms of a left knee disorder were not chronic in service, were not continuous since service, were not shown to a compensable degree within one year of service, and were not shown for many years after service. 3. A current left knee disorder, diagnosed as total knee joint replacement and posttraumatic arthritis, is not causally or etiologically related to service. 4. A low back injury or disease was not shown in service. 5. A low back disorder, diagnosed as degenerative disc disease of L4-S1 disc space and a herniated disc with arthritis, was not shown to a compensable degree within one year of service; symptoms of a low back disorder were not continuous since service. 6. A current low back disorder is not causally or etiologically related to service. CONCLUSIONS OF LAW 1. A left knee disorder was not incurred in or aggravated by service, and may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 1112, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2013). 2. A low back disorder was not incurred in or aggravated by service, and may not be presumed to have been so incurred or aggravated, nor is it secondary a service connected disability. 38 U.S.C.A. §§ 1110, 1112, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2013). Service connection may be established under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). In this case, the Veteran has been diagnosed with diagnosed as degenerative disc disease of L4-S1 disc space and a herniated disc with arthritis as well as a total left knee joint replacement and posttraumatic arthritis of the left knee. Arthritis is listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the "chronic" in service and "continuous" post-service symptom presumptive provisions of 38 C.F.R. § 3.303(b) only apply to "chronic" diseases at 3.309(a)). Service connection may also be established with certain chronic diseases, including arthritis, based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Service connection may also be established for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). This has been interpreted as a three-element test based on nexus: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). In addition to the regulations cited above, service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. The Board notes that 38 C.F.R. § 3.310 was amended effective October 10, 2006. Under the revised § 3.310(b) (the existing provision at 38 C.F.R. § 3.310(b) was moved to sub-section (c)), any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service-connected. As the Veteran filed the claim for service connection for a low back disorder, to include as secondary to a service-connected disability, in December 2005, the amendment is not applicable to the current claim. Further, active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. 38 U.S.C.A. § 101(21), (24); 38 C.F.R. § 3.6(a), (d); Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). ACDUTRA is defined as full-time duty in the Armed Forces performed by Reserves for training purposes, and includes full-time duty performed by members of the National Guard of any State. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c)(1). Thus, service connection may be granted for a disability resulting from disease or injury incurred or aggravated while performing ACDUTRA or from an injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131. Presumptive periods do not apply to ACDUTRA or INACDUTRA. 38 C.F.R. § 3.6(c)(1). Therefore, consideration of 38 C.F.R. §§ 3.307 and 3.309 (presumptive service connection for certain chronic diseases) for the periods of ACDUTRA or INACDUTRA is not appropriate. Id. In this decision, the Board has considered the lay and medical evidence as it pertains to the Veteran's claims. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is 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); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). "Competent medical evidence" means that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). "Competent lay evidence" is any evidence not requiring that the proponent have specialized education, training or experience, but is provided by a person who has the 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); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of his or her active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). The Board has reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Left Knee Disorder In this case, the Veteran seeks service connection for a left knee disorder. He asserts that his left knee disorder is related to service, specifically to an in-service motor vehicle accident in 1963. He does not relate it to any periods of ACDUTRA or INACDUTRA or to his second period of active duty in 1991. The evidence of record demonstrates that the Veteran has a current left knee disability. Specifically, at a December 2003 VA examination, he was diagnosed with status post left knee arthrotomy, residual posttraumatic arthritis of the left knee. A September 2011 VA examination report notes that he underwent left knee joint replacement surgery in 1985. At the VA examination, he reported that he had a daily mild ache in his left knee since surgery. Therefore, a current left knee disorder is shown. Next, the Board notes an in-service incurrence of an injury to the left knee. Specifically, service treatment records reflect that the Veteran was treated for a left knee strain after having been hit by a motor vehicle in March 1963. Subsequent records reflect left knee complaints including a notation of weakness in June 1963 and a notation of occasional "slip[ping out]" of the left knee at the August 1964 service separation physical. However, the clinical evaluation of the lower extremities was normal. Therefore, service treatment records reflect an in-service left knee injury and the second element has been met; however, the service treatment records do not show a chronic left knee disorder. As such, service connection is not established under the chronicity provision of 38 C.F.R. § 3.303(b). Next, as the Veteran's current left knee disorder is a chronic disability under 38 C.F.R. § 3.309(a), the Board will consider whether continuity of symptomatology has been shown under the continuity provision of 38 C.F.R. § 3.303(b). Next, post-service evidence does not reflect left knee symptomatology for many years after service discharge. Specifically, the Veteran underwent multiple examinations in February 1986, July 1990, and January 1991 as part of his Reserve duty. At all three, he denied any history or complaints of symptoms related to the left knee and his lower extremities were found to be clinically normal. A November 1993 private treatment record shows complaints of left knee pain after the Veteran fell during a basketball game, which led to surgery on the left knee. This is the first recorded symptomatology related to a left knee disorder, coming some 39 years after the occurrence of the left knee injury in service in 1963 to 1964. Even accepting that total knee joint replacement surgery was conducted on the Veteran's left knee in 1985, this event still occurred some 21 years after the occurrence of the left knee injury in service. Therefore, the medical evidence does not reflect continuity of symptomatology. In addition to the absence of documented post-service symptomatology related to the left knee for many years, the evidence includes the Veteran's statements and sworn testimony asserting continuity of symptoms. The Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). At the September 2011 VA examination, he indicated that he continued to experience symptoms relating to the left knee after he was discharged from service. Nonetheless, the Board finds that his reported history of continued symptomatology since active service, while competent, is nonetheless not credible. Significantly, the Board finds that the reported history of continued left knee pain since active service is inconsistent with the other evidence of record. Indeed, while the Veteran stated that his disorder began in service and did attest of a "trick" or locked knee at the August 1964 service separation physical, he denied any history or complaints of symptoms of a left knee disorder, including having a "trick" or locked knee, at the March 1991 service separation physical. Additionally, as noted above, while in the Army Reserve, he underwent physicals in February 1986, July 1990, and January 1991. At all three physicals, his lower extremities were found to be clinically normal, he denied having a "trick" or locked knee, and he did not report any complaints of left knee pain. His in-service history of symptoms at the time of service separation is more contemporaneous to service, so is of more probative value than the more recent assertions made many years after service separation. 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). Next, while not dispositive, the post-service evidence does not reflect complaints or treatment related to a left knee disorder for at least 13 years following the period of active service during which the original knee injury occurred. In the November 2004 notice of disagreement, the Veteran stated that he went to the VA in 1977 for knee help, but was told he had his own insurance. While no medical evidence is of record regarding this visit, the Board emphasizes the multi-year gap between discharge from his initial period active duty service when the left knee injury occurred (1964) to when he first alleged he went to the VA for knee help (1977). See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability); Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (the silence in a medical record can be weighed against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated by the fact finder.) Further, the Board also emphasizes the fact that while the Veteran claims to have been experiencing symptoms of left knee pain since his initial separation from service in 1964, he denied any history or symptoms of left knee pain at the subsequent service separation physical in March 1991. Moreover, the post-service evidence does not reflect treatment related to the left knee disorder for 39 years following active service. As noted above, even assuming knee symptoms in 1977, his first complaint was more than a decade after separation from service. The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for benefits to be of lesser probative value. See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the veteran's statements, it may consider whether self-interest may be a factor in making such statements). For these reasons, the Board finds that the weight of lay and medical evidence is against a finding of continuity of symptomatology between his current claim and service. In addition, as shown above, the earliest allegation of treatment for the Veteran's left knee disorder was that he attempted to seek help for his knee at VA in 1977, at least 13 years after his initial separation from service in 1964. The first notation of left knee pain following the Veteran's second separation from service in March 1991 was in November 1993 when he injured his knee playing basketball. Therefore, a left knee disability was not shown within the first year of discharge and the presumptions under 38 U.S.C.A. §§ 1112, 1113, 1137 and 38 C.F.R. §§ 3.307, 3.309 do not apply. As such, the appeal is denied on a presumptive basis. Nonetheless, as a left knee disability is currently shown and the evidence reflects an in-service left knee injury, the next question is whether there is a casual relationship between the current complaints and the in-service injury. In this case, the Board finds that the weight of the competent evidence does not attribute the left knee disorder to active duty. In December 2003, the Veteran underwent a VA joints examination. At the examination, he reported pain of the left knee with soreness of the left knee and sometimes swelling. The examiner noted that the Veteran injured his left knee during service in March 1963 when he was hit by a jeep, sprained his right ankle playing basketball in December 1963, and reinjured his left knee playing basketball after service. The examination report notes that the Veteran had surgery on his left knee in 1993 followed by physical therapy. The examiner diagnosed the Veteran with residual posttraumatic arthritis in the left knee and opined that the left knee trauma was "service connected" and also after service in 1993. The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). Unfortunately, because the examiner did not provide a rationale or nexus opinion as to the etiology of the Veteran's left knee disorder, the Board accords this opinion little probative weight. In a September 2005 letter, a private treating physician expressed his opinion that the Veteran's "knee injury . . . occurred while he was in the Armed Forces." Pursuant to the Board's August 2008 remand, he underwent another VA examination in September 2011. He reported he had injured his left knee during service in 1963. The examination report notes that service treatment records reflect treatment for the left knee in March 1963, June 1963, and August 1964. The Veteran reported intermittent difficulty of pain and swelling with the left knee from active discharge in 1964 until undergoing a total knee replacement in 1985. He reported improved discomfort since the knee replacement, but reported a mild, daily ache since surgery. He did not report any flare ups or incapacitating episode. The VA examiner diagnosed the Veteran with left total knee replacement from March 1985, based on the history provided. He denied any other knee surgeries. Imaging studies were not conducted. The examiner opined that he was unable to relate minor knee problems in service, a total of three visits, to a knee replacement in 1985 because there was no evidence of continuity of care from service separation in 1964 to the total left knee replacement in 1985. The examiner noted that the Veteran was involved with the Army Reserve following service separation until 2005 and that, with the exception of the 2005 letter from the private treating physician, the record was absent of any records to show a continuity of care or problems. The examiner also noted that the 1964 service separation physical did not note any knee problems. The Board finds the September 2011 VA examination opinion highly probative. Specifically, the examiner reviewed the claims file, interviewed the Veteran, and conducted a physician evaluation. There is no indication that the VA examiner was not fully aware of the Veteran's past left knee history or that he misstated any relevant fact. Moreover, the examiner has the requisite medical expertise to render a medical opinion regarding the etiology of the disorder and had sufficient facts and data on which to base the conclusion. The VA examination opinion contained reasons and bases supporting the examiner's opinion that the Veteran's current left knee disorder was not causally related to his active service. Conversely, the September 2005 letter from the private treating physician only stated that the Veteran's left knee injury occurred in service. However, he did not provide any rationale to support his opinion. The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). Additionally, the private physician did not indicate whether he had access to, and thus an opportunity to review, the claims folder, including the in-service and post-service medical evidence contained therein. As such, the Board accords the September 2005 letter lesser probative weight. In this decision, the Board has also considered the Veteran's lay statements as they pertain to a nexus between current complaints and service. In a January 2008 written statement, he stated that, while he was in service, a military physician told him that his left knee would collapse. At the September 2011 VA examination, he reported intermittent difficulty of pain and swelling with the left knee from active discharge in 1964. The Board has weighed the Veteran's statements as to nexus and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, the absence of complaints or treatment for years after service, and the September 2011 VA examination report. Moreover, as a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorder of posttraumatic arthritis and total joint replacement of the left knee. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). Arthritis is also a medically complex disease process because of its multiple etiologies, requires specialized testing to diagnose, and manifest symptomatology that overlaps with other disorders. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). The etiology of the Veteran's current left knee disorder is a complex medical etiological question involving internal and unseen system processes unobservable by the Veteran and he is not shown to have such knowledge, training, or experience to differentiate such symptoms or as to all possible etiologies of arthritis. For the reasons stated above, the Board finds that the weight of the evidence is against a finding of nexus between his current claim and service. Finally, the evidence of record does not indicate, nor has the Veteran alleged, that he suffered an injury or disease during a period of ACDUTRA or an injury during INACDUTRA that would have caused his claimed left knee disability. While in the Army Reserve, he underwent physicals in February 1986, July 1990, and January 1991. As noted, his lower extremities were found to be clinically normal, he denied having a "trick" or locked knee, and he did not report any complaints of left knee pain. In a March 1998 Report of Medical History, the physician noted that the Veteran had a history of a fracture in his left knee but did not relate this injury to any period of ACDUTRA or INACDUTRA. Rather, the evidence shows no relevant injury or disease during a period of ACDUTRA, or a relevant injury during INACDUTRA. In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection for a left knee disorder and there is no doubt to be otherwise resolved. As such, the appeal is denied. Low Back Disorder As part of his current VA disability compensation claim, the Veteran has asserted that his low back disorder is related to service or was caused by or aggravated by a service connected disability. Specifically, he contends that his nonservice-connected left knee disorder has caused his low back disorder. The evidence of record demonstrates that the Veteran has a current low back disability. A September 2003 private treatment record notes mild narrowing of the L4 to S1 intervertebral disc spaces. A January 2005 letter from a private treating physician notes that the Veteran had degenerative disc disease with associated herniation of disc at LF level. At a September 2011 VA examination, he was diagnosed with diagnosed as degenerative disc disease of L4-S1 disc space and a herniated disc with arthritis. Therefore, a current back disorder is shown. The service treatment records reflect no treatment for or diagnoses related to the low back and there was no reference to a back injury of any kind. At the August 1964 service separation physical, the spine was found to be clinically normal and the Veteran did not endorse any problems of back pain. The Board notes that he endorsed recurrent back pain at the March 1991 service separation physical. As the Veteran's current low back disorder is a chronic disability under 38 C.F.R. § 3.309(a), the Board will consider whether continuity of symptomatology has been shown. At the August 1964 service separation physical, the Veteran's spine was found to be clinically normal. On an associated Report of Medical History, he did not endorse any symptoms of a low back disorder. At the March 1991 service separation physical, he reported recurrent back pain. Upon physical examination, the spine was found to be clinically normal. The service treatment records indicate no other complaints of low back symptomatology for either period of service. Next, post-service evidence does not reflect low back symptomatology for many years after service discharge. Specifically, a March 1998 Report of Medical History conducted in relation to the Veteran's Reserve duties is the first evidence of record that he experiences low back pain. A September 2003 letter from a private physician noted that he had mild narrowing of the L4 to S1 intervertebral disc spaces. Thus the first recorded symptomatology related to a low back disorder comes some 7 years after service separation. Therefore, the medical evidence does not reflect continuity of symptomatology. In addition to the absence of documented post-service symptomatology related to the low back for many years, the evidence includes the Veteran's statements and sworn testimony asserting continuity of symptoms. At the September 2011 VA examination, he reported he has had low back pain since the early 1980s. At the January 2008 Board hearing, he reported that his back gave out approximately seven to ten years, but that, prior to that, when he had back pain he would obtain Valium from the dispensary. In this case, the Board finds that the Veteran's reported history of continued symptomatology since active service, while competent, is nonetheless not credible. Significantly, the Board finds that the reported history of continued low back pain since active service is inconsistent with the other evidence of record. The Veteran did not endorse symptoms of back pain at the August 1964 service separation physical. Indeed, while he did attest to recurrent back pain at the March 1991 service separation physical, the service separation physical report reflects that he was examined and his spine was found to be clinically normal. His in-service history of symptoms at the time of service separation is more contemporaneous to service, so is of more probative value than the more recent assertions made many years after service separation. 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). Moreover, the Veteran has been vague and inconsistent as to his own statements as to the onset of symptoms. As stated above, he reported low back pain since the early 1980s at the September 2011 VA examination, but endorsed back pain for approximately seven to ten years at the January 2008 Board hearing. These vague and inconsistent statements in the record as to the onset of symptoms weigh against his credibility as to onset of symptoms. See Gardin v. Shinseki, 613 F.3d 1374, 1380 (Fed. Cir. 2010) (upholding Board finding that vague and inconsistent lay statements were not credible because they were in direct contradiction to the more credible, competent, reliable, and clearly documented medical evidence). The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for benefits to be of lesser probative value. See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the veteran's statements, it may consider whether self-interest may be a factor in making such statements). For these reasons, the Board finds that the weight of lay and medical evidence is against a finding of continuity of symptomatology between his current claim and service. In addition, the first notation of low back pain following the Veteran's second separation from service in March 1991 was in a March 1998 report of medical history for the Army Reserve. Therefore, a low back disability was not shown within the first year of discharge and the presumptions under 38 U.S.C.A. §§ 1112, 1113, 1137 and 38 C.F.R. §§ 3.307, 3.309 do not apply. As such, the appeal is denied on a presumptive basis. Nonetheless, as a low back disability is currently shown and the evidence reflects an in-service complaint of recurrent back pain, the next question is whether there is a casual relationship between the current complaints and the in-service back pain. In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran's low back disorder to active duty, despite his contentions to the contrary. To that end, the Board places significant probative value on the September 2011 VA examination undertaken specifically to address the issue on appeal. After a physical examination, the examiner diagnosed degenerative disc disease of L4-S1 disc space and herniated disc with arthritis. The Veteran reported low back pain and stated that, while there was no specific injury, he believed this pain was due to the strain of military activity and physical expectations of a reservist until 2005. The Veteran reported a constant daily pain, located in his lower back without radiation, since 2005. The examiner opined that the Veteran's low back disorder was less likely than not incurred in or caused by his active service because there was no evidence of back problems in service and that, despite his back complaints, the Veteran was a Reservist until 2005. The examiner also noted that there is no evidence to indicate that the Veteran's left knee problem caused his back disorder. The Board finds the September 2011 VA examination opinion adequate for evaluation purposes. Specifically, the examiner reviewed the claims file, interviewed the Veteran, and conducted a physician evaluation. There is no indication that the VA examiner was not fully aware of the Veteran's past low back history or that he misstated any relevant fact. Moreover, the examiner has the requisite medical expertise to render a medical opinion regarding the etiology of the disorder and had sufficient facts and data on which to base the conclusion. The VA examination opinion contained reasons and bases supporting the examiner's opinion that the Veteran's current low back disorder was not causally related to his active service. The Board notes a September 2005 letter from a private treating physician that states the Veteran's low back pain was causally related to a knee injury which occurred during active service. However, the letter does not opine as to whether the Veteran's low back disorder was incurred in or caused by his active service and rather speaks only to the Veteran's contention of secondary service connection. In this decision, the Board has also considered the Veteran's lay statements as they pertain to a nexus between current complaints and service. As stated above, at the September 2011 VA examination, the Veteran stated that he believed his current low back pain is due to the strain of military activity and physical expectations of a Reservist until 2005. At the January 2008 Board hearing, he reported that, after he was hit by a motor vehicle in service in March 1963, the military physician treating him told him that in 30 years he would be suffering with his back. He stated that he has had back pain since service separation. The Board has weighed the Veteran's statements as to a nexus and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, the absence of complaints or treatment for years after service, and the September 2011 VA examination report. Moreover, as detailed above, as a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorder of degenerative disc disease of L4-S1 disc space and a herniated disc with arthritis. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). The etiology of the Veteran's current low back disorder is a complex medical etiological question involving internal and unseen system processes unobservable by the Veteran and the Veteran is not shown to have such knowledge, training, or experience to differentiate such symptoms or as to all possible etiologies of arthritis. For the reasons stated above, the Board finds that the weight of the evidence is against a finding of nexus between his current claim and service. The Veteran has also filed a claim for service connection for a low back disorder as secondary to a service connected disability. However, the Veteran has no service connected disabilities and therefore service connection for a low back disorder as secondary to a service-connected disability must be denied as a matter of law. See 38 C.F.R. § 3.310; Sabonis v. Brown, 6 Vet. App. 426 (1994). Finally, the evidence of record does not indicate, nor has the Veteran alleged, that he suffered an injury or disease during a period of ACDUTRA or an injury during INACDUTRA that would have caused his claimed low back disability. While in the Army Reserves, the Veteran underwent physicals in February 1986, July 1990, and January 1991. At all three physicals, the Veteran's spine was found to be clinically normal and he denied recurrent back pain. In a March 1998 Report of Medical History, he endorsed recurrent back pain but did not allege a specific injury or disease that occurred. Rather, the evidence shows no relevant injury or disease during a period of ACDUTRA, or a relevant injury during INACDUTRA. In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection for a low back disorder, to include as secondary to a service connected disability, and there is no doubt to be otherwise resolved. As such, the appeal is denied. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). For the claim for service connection for a left knee disorder, notice was provided to the Veteran in March 2004, prior to the initial adjudication of the claim for service connection in November 2004. He was notified of the evidence not of record that was necessary to substantiate the claim, as well as of VA and his respective duties for obtaining evidence. Although the March 2004 notice provided did not address either the rating criteria or effective date provisions that are pertinent to the claim, such error was harmless given that service connection is being denied; hence, no rating or effective date will be assigned with respect to this claimed condition. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice regarding effective dates and rating criteria was subsequently provided to the Veteran in a March 2006 letter. For the claim for service connection for a low back disorder, notice was provided to the Veteran in June 2006 as to the claim for direct service connection, prior to the initial adjudication of the claim for service connection in December 2006. In the August 2008 remand, the Board instructed the RO to provide him with VCAA notice with regard to his claim of secondary service connection for his low back. This notice was provided in June 2011, his claim was subsequently readjudicated, and a supplemental statement of the case was issued in November 2011. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). Thus, the Board concludes that VA satisfied its duties to notify. VA satisfied its duty to assist the Veteran in the development of the claim. First, VA satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file includes service treatment records, Reserve treatment records, private treatment records, VA examination reports, Board hearing transcript, Board remand, and the Veteran's lay statements. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the issue that has not been obtained. Thus, the Board concludes that VA has made every reasonable effort to obtain all records relevant to the appeal. Second, VA satisfied its duty obtain a medical opinion when required. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran was provided with a VA examination for his left knee disorder (the report of which has been associated with the claims file) in December 2003. In August 2008, the Board remanded the issues on appeal, in part, to provide him with another VA examination to address the nature, extent, and etiology of his left knee and low back pathology. The Veteran was provided with a VA examination (the report of which has been associated with the claims file) in September 2011. The Board finds this VA examination was thorough and adequate and provides a sound basis upon which to base a decision with regard to the claim. The VA examiner personally interviewed and examined the Veteran, including eliciting a history from him, and provided the information necessary to evaluate his disabilities. Neither the Veteran nor his representative has questioned the adequacy of the VA examination. Additionally, the Veteran testified at a hearing before the Board in January 2008, a transcript of which has been associated with the claims file. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Finally, in August 2008, the Board remanded these claims for further development and to ensure that all due process requirements were satisfied. In Stegall v. West, 11 Vet. App. 268, 271 (1998), the Court held that a remand by the Board confers upon the veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand. See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall). In its August 2008 remand, the Board instructed the RO to send the Veteran a VCAA notice letter compliant with the requirements set forth in the section above and which informed him to submit any pertinent evidence in his possession. Such a notice letter was sent in June 2011. The Board also instructed the RO to obtain additional left knee and low back treatment records not already associated with the claims file. There are no outstanding VA treatment records not of record and he has not submitted any additional private records nor provided the appropriate release of information forms for VA to obtain additional private treatment records on his behalf. Finally, the Board instructed the RO to provide appropriate VA examinations and thereafter to readjudicate the claims. As discussed above, the Veteran was provided such an examination in September 2011 and the Board finds that it was adequate and responsive to the Board's remand directives. The claims were readjudicated in November 2011 and a supplemental statement of the case was issued. As such, the Board finds that there has been substantial compliance with its August 2008 remand directives and therefore no further action is required. See Stegall, 11 Vet. App. at 271; D'Aries, 22 Vet. App. at 105. ORDER Service connection for a left knee disorder is denied. Service connection for a low back disorder is denied. ____________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs