Citation Nr: 1334941 Decision Date: 10/31/13 Archive Date: 11/06/13 DOCKET NO. 03-08 088 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to service connection for a left leg disorder. 2. Entitlement to service connection for degenerative joint disease of the left knee. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from August 1972 to February 1974 and on active duty for training (ACDUTRA) from July 1982 to September 1982. He also served in the National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a January 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York that in relevant part denied service connection for residuals of a left leg injury and meniscus repair of the left knee. In his Substantive Appeal, the Veteran requested a hearing before the Board, and he was duly scheduled to appear before a Member of the Board sitting at the RO ("Travel Board" hearings) in December 2008 and July 2011. He failed to appear at the scheduled hearings, and his request for a hearing before the Board is accordingly deemed to be withdrawn. See 38 C.F.R. § 20.704(d) (2013). The Board remanded the case to the Agency of Original Jurisdiction (AOJ) in August 2012 for additional development, which has been accomplished. Stegall v. West, 11 Vet. App. 268 (1998). The AOJ most recently adjudicated the claim in April 2013 and issued a Supplemental Statement of the Case (SSOC). The Veteran thereafter submitted a letter to the Board in June 2013 containing additional argument in support of his claim. The Veteran enclosed a waiver of AOJ jurisdiction, and the Board has accepted the Veteran's correspondence for inclusion into the record on appeal. See 38 C.F.R. § 20.800 (2013). FINDINGS OF FACT 1. The Veteran does not have a current left leg disability that is etiologically related to service. 2. Degenerative joint disease of the left knee did not become manifest during service or to a compensable degree within the first year after discharge from service and is not etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for a left leg disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2013). 2. The criteria for establishing service connection for a left knee disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Before addressing the merits of the Veteran's claim on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2013). The VA is required to assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The VA is required to notify a claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, the VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, the VA will attempt to obtain on behalf of the claimant. In addition, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant be provided "at the time" of, or "immediately after," the VA's receipt of a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). VA must also notify the claimant that, should service connection be awarded, a disability rating and an effective date for the award of benefits will be assigned. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran in this case was not provided fully-compliant notice prior to the January 2002 rating decision on appeal, in that he was not informed of the disability-rating and effective-date elements of a service connection claim. However, during the course of the appeal the Veteran was provided compliant notice and thereafter the RO readjudicated the claim. Where there is a timing defect in a case, VA may cure the defect through compliance via proper remedial measures, such as the issuance of compliant VCAA notice followed by readjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The readjudication may come in the form of the issuance of an SOC or SSOC following the issuance of the VCAA notice. Mayfield, id.; Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006). To the degree there was a timing defect in the notice provided the Veteran, such defect has been cured. In any event, the Veteran has not identified any prejudice due to error in the content or timing of the notice provided. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The RO has obtained service treatment records (STRs), service personnel records, disability records from the Social Security Administration (SSA) and post-service treatment records from those VA and non-VA providers the Veteran has identified as having treatment records that could be relevant to the issues on appeal. As noted in the Introduction, the Veteran has twice been scheduled to testify before the Board, and on both occasions he failed to report. When the file was last before the Board, the Board determined the Veteran should be afforded another VA examination in order to obtain an adequate medical opinion regarding the etiology of the claimed disorders. The examination was performed in March 2013. The Board has reviewed the examination report and finds the AOJ substantially complied with the Board's remand directive. D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Board also finds that the medical evidence of record is sufficient at this point for the Board to adjudicate the appeal. Neither the Veteran nor his representative has made the AOJ or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and neither has argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced the Veteran in the adjudication of his appeal. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the issues on appeal. Applicable Laws and Regulations Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Where a veteran served for at least 90 days during a period of war or after January 1, 1947, and manifests arthritis to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. A veteran is presumed to have been in sound condition when enrolled for service, except for any disease or injury noted at the time of enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before enrollment and was not aggravated by such service. Only such conditions as are recorded in examination reports are to be considered as noted. A veteran's reported history of the pre-service existence of a disease or injury does not constitute notation of such disease or injury, but is considered with all other evidence in determining if the disease or injury pre-existed service. 38 U.S.C.A. §§ 1111, 1137 (West 2002); see Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); 38 C.F.R. § 3.304(b) (2013). If a disorder was not noted on entering service, the government must show clear and unmistakable evidence of both a preexisting condition and a lack of in-service aggravation to overcome the presumption of soundness for wartime service under 38 U.S.C.A. § 1111. A lack of aggravation may be shown by establishing that there was no increase in disability during service or that any "increase in disability [was] due to the natural progress of the preexisting condition." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 U.S.C.A. § 1153. If the government fails to rebut the section 1111 presumption, the claim is one for service connection, not aggravation. Id. Active Duty for Training (ACDUTRA) is defined as full-time duty in the Armed Forces performed by Reserves for training purposes. 38 U.S.C.A. § 101(22). Service connection may be granted for residuals of injuries incurred in ACDUTRA; see 38 U.S.C.A. § 101(24). However, in the service connection context, the presumption of soundness upon entry into service, and the presumptive provisions of service connection under 38 C.F.R. § 3.307, are not applicable to periods of ACDUTRA. See 38 U.S.C.A. §§ 1111, 1112, 1137; 38 C.F.R. § 3.307; see also Biggins v. Derwinski, 1 Vet. App. 474, 476-78 (1991). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Evidence Service treatment records (STRs) relating to the Veteran's period of active duty from 1972-1974 are of record. There is no indication of any injury to the left knee. The Veteran complained in July 1973 of a sore muscle in the left leg, possibly a pulled muscle, but this was apparently resolved with pain medication. A self-reported Report of Medical Examination in January 1974 shows the Veteran denied lameness or other bone/joint disorder, and the corresponding Report of Medical Examination shows clinical evaluation of the lower extremities as "normal." The Veteran was discharge from service shortly thereafter in February 1974. The Veteran does not assert that his current claimed disabilities of the left knee and left leg are related to active service in 1972-1974. Rather, he asserts his claimed disabilities are residual to an injury incurred during active duty for training (ACDUTRA) in 1982 that resulted in knee injury and also in stress fracture to the leg. The Veteran has asserted in his correspondence to VA that he had chronic knee problems after the injury in ACDUTRA until his anterior cruciate ligament (ACL) finally tore in 1984. STRs associated with the Veteran's Reserve Component service include an enlistment physical examination into the Army Reserve in July 1982. In a self-reported Report of Medical History the Veteran reported having had a left leg fracture at age 8, and the examiner endorsed history of left leg fracture at age 8 with no sequelae. The corresponding Report of Medical Examination shows clinical evaluation of the lower extremities as "normal." The Veteran performed ACDUTRA during the period July-September 1982. STRs associated with ACDUTRA show the Veteran presented on August 2 complaining of pain and popping in the left knee. The clinical impression was patellofemoral tendonitis, and the Veteran was placed on temporary profile for the period August 2-12 due to left tibia stress injury. On August 12 he complained of swelling incurred while using the weight machine and his profile was extended to August 27, and thereafter to September 5, for patellofemoral tendonitis. A VA medical certificate dated January 29, 1984, shows admission for surgery for interior derangement of the left knee. A subsequent treatment note dated in March 1984 anachronistically refers to history of surgery in January 1985 and to an "old injury" in June 1985. On review of the inconsistencies in these dates, and on careful comparison with the VA treatment dates cited below, it is clear to the Board that these entries are misdated and actually represent an admission on January 29, 1985, and that they refer to an injury that occurred in June 1984. A VA treatment note dated in December 1984 states the Veteran had twisted his left knee while running six months earlier (i.e., in approximately June 1984) and had chronic pain and instability since then. The Veteran denied any knee problems prior to the present complaint. The Veteran thereupon underwent diagnostic arthroscopy, which demonstrated detachment of the anterior horn of the medial meniscus, which was repaired. The Veteran was also identified as having an anterior cruciate deficient knee, and he was scheduled for an ACL repair in January. The discharge diagnosis was left knee medial meniscal detachment with ruptured ACL. Thereafter, the Veteran underwent ACL reconstruction surgery at VA on January 29, 1985. The clinical history specifically noted the injury was incurred on June 20, 1984, while running. Postoperative treatment records in February 1985 and April 1985 also specifically report that the Veteran's knee injury was incurred by stepping into a hole while running in June 1984. VA X-ray of the left knee in October 1985 showed post-surgical changes, without evidence of acute fractures or effusions. A VA physical therapy consult in March 1986 states the Veteran's injury was consequent to running in a race in June 1984. In December 1986 the Veteran presented to the VA clinic complaining that he had slipped on a piece of ice and twisted his left knee. He endorsed previous knee surgery in 1985. The Veteran presented to the VA clinic in August 1987 complaining of knee pain. He reported having twisted the knee that day while lifting boxes. X-ray of the left knee showed no significant interval changes since the previous study in October 1985; a metallic staple was identified on the tibial plateau, as well as bony changes in the same area, but the spaces were well maintained and there was no joint effusion. The X-ray impression was evidence of post-surgical changes. The Veteran had a National Guard enlistment examination in September 1988. In the self-reported Report of Medical History he endorsed a history of remote left leg fracture at age 16 (noted as "healed") and history of surgery for ACL repair in 1985 (noted as "healed, full use"). The corresponding Report of Medical Examination showed a clinical impression of "normal" lower extremities The Veteran presented to the VA clinic in November 1988 complaining of pain related to receiving a sharp blow to the left knee while he was sitting with his knee flexed. Clinical examination was grossly normal. The impression was rule out strain to the left lateral longitudinal ligament. The Veteran presented to the VA clinic in January 1992 complaining that his left knee "gave out" and caused him to fall. The clinical impression was ACL injury. The Veteran had a VA X-ray of the left knee in January 1992 to rule out fracture. Post-surgical changes were identified, but no acute fractures or dislocations were seen and the soft tissues, joint space and bony mineralizations were normal for the Veteran's age. The clinical impression was post-operative changes but no acute processes. In March 1992 the Veteran reported to a VA clinician that he had ACL reconstruction six years previously (i.e., 1985) and was doing well until he fell recently, causing his knee to buckle. Since that recent injury he had been experiencing much pain and tendency to give way. The clinical impression was rule out meniscal tear and loose body. The Veteran was referred for MRI to rule out meniscal tear; the impression from the MRI was identified metallic artifact but otherwise grossly unremarkable study. The Veteran had a left knee arthroscopy by VA in April 1992. The treatment report notes previous ACL reconstruction in 1985 and subsequent re-injury in January 1992 while stepping off a curb. Diagnostics had not shown any abnormality, but the Veteran continued to complain of discomfort, so diagnostic arthroscopy was performed. The ACL and meniscus looked good; inspection was significant for synovitis with scarring. The post-operative impression was internal knee derangement with scarring. The Veteran had a VA medical examination in June 1998 in which he reported a knee injury incurred in a slip-and-fall while running in 1982. A torn ACL was demonstrated by arthroscopy in June 1984 and repaired in January 1985; the Veteran did well afterward using a brace, but the brace had since become too small. The persistence of pain and swelling in the knee led to another arthroscopy in 1992, which noted no abnormality in the medial compartment (the lateral compartment was inaccessible); the joint was flushed and the procedure was terminated. Since that time, the Veteran had problems with swelling, stiffness and pain. The examiner performed a clinical examination of the knee and noted observations in detail. A current X-ray of the left knee showed an impression of previous surgery with a staple identified overlying the lateral supracondylar level of the knee joint space of the left distal femur and mild degenerative changes with narrowing of the knee joint space, especially laterally. The examiner's diagnostic impression was status post left knee injury. A June 1998 discharge report from the VA emergency room shows diagnosis of degenerative joint disease (DJD). The Veteran had a VA MRI of the left knee in July 1998. The clinical history noted status post stapling of the knee in 1985, and the intent of the test was to evaluate for DJD versus torn medial meniscus. The impression was no gross evidence of meniscal tear, apparently intact ACL (with possible mild degree of impingement) and tricompartmental arthrosis consistent with chondromalacia patella. The Veteran presented to the VA orthopedic clinic in July 1998 complaining of instability in the left knee; he asked for an immobilizer until such time as his knee could be evaluated. The clinician stated the knee was surprisingly stable on examination; the clinician could not feel any anterior or posterior drawer but the Veteran subjectively complained of minimal discomfort with valgus stress. The clinician indicated a plan to repeat an MRI, and the clinician provided the Veteran with the requested knee immobilizer. The clinician noted the Veteran stated he was trying to get 100 percent disability evaluation. In an orthopedic clinic follow-up in August 1998 the clinician stated the Veteran's 1985 ACL repair had left him with a very stable knee. At most, one could calculate the Veteran might have a grade I instability to the Lachman's test but nothing on the drawer test. Medial and collateral ligament stability were excellent, posterior cruciate ligament was "quite strong" and McMurray's was negative. There was an ever-so-small amount of crepitus in the knee. The clinician stated that at most the Veteran had a successful ACL reconstruction with a minor amount of chondromalacia patella in the left knee. The Veteran's SSA disability file includes an examination performed by Industrial Medicine Associates (IMA) Disability Services in August 1998 in which the Veteran reported having injured his knee in 1984 while running, with subsequent ACL repair in 1985. The examiner diagnosed status post ACL repair of the left knee with history of DJD and some limitation of flexion of the left knee joint. The Veteran had a VA examination in June 2005, performed by a physician who reviewed the claims file. The examiner noted a closed fracture of the left tibia prior to service, treatment during ACDUTRA and subsequent ACL repair in January 1985. The examiner performed a clinical examination of the left leg and knee and diagnosed chronic left knee pain and status post ACL repair. The examiner stated an opinion that the preexisting left tibia closed fracture was not aggravated due to the natural progression of the disability. In an addendum to the June 2005 VA examination, the examiner clarified his opinion to state that the Veteran's preexisting left leg fracture was not likely aggravated during ACDUTRA beyond the natural progression of the disability because the fracture had healed. The Veteran's SSA disability file includes an examination performed by IMA in December 2005 in which he reported a history of longstanding knee pain after a running accident in 1985, with subsequent ACL repair. Contemporaneous left knee X-ray showed an impression of status post ACL repair; otherwise, normal examination. The examiner's diagnosis was left knee pain with history of ACL repair secondary to ligamentous involvement. The Veteran's most recent VA examination was performed in March 2013, by a physician who reviewed the claims file. The Veteran reported having experienced left knee pain in the summer of 1982 (during ACDUTRA) and being put on profile at the time for left patellofemoral tendonitis. He reported having attended physical therapy at VA thereafter, but the examiner was unable to find any supporting documentation. The Veteran reported that thereafter he tore his ACL while running in June 1984, with resulting arthroscopy and repair. The examiner performed a clinical examination of the knee and noted observations in detail. The examiner diagnosed ACL tear and DJD of the left knee. The examiner stated an opinion that the Veteran's claimed disability was not likely incurred or caused by the claimed in-service injury or event. As rationale, the examiner stated the Veteran's current knee condition is directly related to the ACL tear in 1984. The Veteran's symptoms in service in 1982 were diagnosed as patellofemoral tendonitis, which would have no relationship to an ACL tear in 1984; rather, it would be considered a temporary condition and would not in any way have an etiologic relationship to a later ACL tear. The Veteran also did have a fracture of his left tibia/fibula in grade school, which was treated with a cast and from which he has no current residuals. The Veteran submitted a letter to VA in June 2013 asserting that he had not been given a proper examination with X-rays during ACDUTRA. He asserted he had problems with the knee from the time of his injury until surgery was finally performed. Analysis STRs demonstrate that the Veteran had treatment during service for stress fracture. However, that a condition or injury occurred in service alone is not enough; there must be a disability resulting from that condition or injury. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1993). Existence of current disability must be shown by competent medical evidence. Degmetich v. Brown, 104 F.3d 1328 (1997). "Current disability" means a disability shown by competent medical evidence to exist at the time of the award of service connection. Chelte v. Brown, 10 Vet. App. 268 (1997). In this case, although there was documented stress fracture in ACDUTRA, there is no indication that such injury has resulted in any disabling residuals. The Veteran's post-1982 treatment records show no X-ray evidence of any residuals of stress fracture, and the only complaints relating to the Veteran's left lower extremity (LLE) over time have been in regard to the knee. Significantly, there is no medical evidence of any diagnosed disorder of the LLE other than a left knee disorder, variously diagnosed. Finally, the VA examiner in March 2013 specifically stated that the stress fracture during ACDUTRA had no current residuals. "Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability ... in the absence of a proof of present disability there can be no claim." Brammer, 3 Vet. App. 223, 225. Given the absence of any current diagnosed disorder of the left leg, the Board finds the Veteran has not shown a disability of the left leg for which service connection can be considered. The Veteran's representative submitted an Informal Hearing Presentation in July 2013 arguing that VA must show by clear and unmistakable evidence that the Veteran's preexisting left leg fracture was not aggravated by service. The Board disagrees. As noted in the discussion above, the Veteran does not have a current disabling condition that is etiologically related to the remote tibia/fibula fracture, so there is no basis upon which service connection can be established. Thus, the question of aggravation of the pre-existing injury during service need not be reached. See Holton v. Shinseki, 557 F.3d 1362, 1367 (Fed. Cir. 2009) ("The presumption of soundness . . . does not relieve the veteran of the obligation to show the presence of a current disability and to demonstrate a nexus between that disability and the in-service injury or disease or aggravation thereof."). Turning to the left knee disorder, the Veteran is shown to have DJD, ACL tear and chondromalacia patella. Accordingly, the first element of service connection - medical evidence of a disability - is met. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000). In this case, the uncontroverted medical opinion of record, in the form of the March 2013 VA examination, states that the Veteran's knee injury during ACDUTRA did not cause his current claimed knee disorders. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. The first inquiry is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). In this case, the March 2013 medical examiner was demonstrably fully informed of the factual premises, in that he cited to the Veteran's subjective history as well as the documented medical history. The examiner provided a fully-articulated opinion supported by clinical rationale. Accordingly, the March 2013 examination report is probative under the standard articulated in Nieves-Rodriguez and may be relied upon by the Board. The Board has considered whether presumptive service connection for DJD may be considered under the provisions of 38 C.F.R. § 3.309(a). The Veteran was discharged from active service in February 1974 and released from ACDUTRA in September 1982. There was no evidence of arthritis in X-ray in 1992, and the first medical notation of DJD was not until June 1998. The Board accordingly finds no indication that arthritis/DJD was present to a compensable degree within one year of the Veteran's separation from active service. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza, 7 Vet. App. 498. Accordingly, in addition to the medical evidence cited above the Board has carefully considered the lay evidence offered by the Veteran in the form of his correspondence to VA and his statements to various medical providers and examiners. The Board must consider the purpose for which lay evidence is offered. Washington v. Nicholson, 19 Vet. App. 362 (2005). In this case, the Veteran's lay evidence is offered to show that he had a knee injury during ACDUTRA that caused continuous symptoms and resulted in his current claimed disability. In that regard, for the conditions explicitly recognized as "chronic" under 38 C.F.R. § 3.309(a) (in this case DJD), the provisions of 38 C.F.R. § 3.303(b) provide an alternative method of establishing the second and third elements through a demonstration of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995). However, once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (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"). 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, 7 Vet. App. 498. 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). The Board may not ignore a veteran's testimony simply because he or she is an interested party and stands to gain monetary benefits; personal interest may, however, affect the credibility of the evidence. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board finds the Veteran's account of having chronic left knee problems since the injury in ACDUTRA is not credible because it is inconsistent with other statements made by the Veteran that are of record. In a December 1984 VA treatment note the Veteran specifically denied having had any symptoms prior to the running injury in June 1984. Similarly, during medical treatments related to ACL repair the Veteran consistently cited the running injury in 1984 and to other injuries thereafter, but he never mentioned the incident in ACDUTRA. During two IMA examinations performed in support of SSA benefits - in other words, in a circumstance where he was not pursuing VA disability benefits - the Veteran specifically attributed his current left knee disability to the 1984-1985 running accident, not to the earlier ACDUTRA incident. It has only been in the context of pursuing his claim for service connection - which is to say, seeking monetary gain - that the Veteran has asserted continuous symptoms since ACDUTRA. The Board finds the statements made while seeking medical treatment are more probative than his current assertions being rendered for the purposes of seeking entitlement to VA compensation. See Buchanan, 451 F.3d at 1336-1337 (conflicting statements of the veteran are factors that the Board can consider and weigh against a veteran's lay evidence); see also Caluza, 7 Vet. App. at 511 (the credibility of a witness can be impeached by a showing of interest, bias, and inconsistent statements). To the degree that the Veteran asserts his personal opinion that his current left knee disorder is etiologically related to injury in ACDUTRA, such opinion is specifically refuted by the medical opinion of the VA examiner. The question of causation of a knee condition is a complex medical question, particularly when there have been numerous traumas over the course of time. Such an opinion is not within the competence of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011). In sum, based on the evidence and analysis above the Board finds the Veteran does not have a current left leg disability or a left knee disability that is etiologically related to service. Accordingly, the claims must be denied. Because the preponderance of the evidence is against the claims the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54-55. ORDER Service connection for a left leg disability is denied. Service connection for left knee disability is denied. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs