Citation Nr: 1335637 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 09-24 840 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for residuals of a right knee injury with degenerative joint disease. 2. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected residuals of a right knee injury with degenerative joint disease. 3. Entitlement to service connection for a right hip disorder, to include as secondary to service-connected residuals of a right knee injury with degenerative joint disease. 4. Entitlement to service connection for a left hip disorder, to include as secondary to service-connected residuals of a right knee injury with degenerative joint disease. 5. Entitlement to service connection for a low back disorder, to include as secondary to service-connected residuals of a right knee injury with degenerative joint disease. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Bosely, Counsel INTRODUCTION The Veteran served on active duty from October 1976 to May 1982. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from December 2007 and February 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In March 2011, the Veteran testified at a Board hearing at the RO. A copy of this transcript is of record. In a September 2012 letter, the Board advised the Veteran that he was entitled to an additional Board hearing as the Veterans Law Judge (VLJ) who had conducted the March 2011 hearing was no longer employed by the Board. See 38 U.S.C.A. § 7102 (West 2002); 38 C.F.R. § 20.707 (2012) (providing that the VLJ who conducts a hearing shall participate in making the final determination on the claim). The Veteran requested a new hearing, and in November 2012, the Board remanded the claim to schedule the Veteran for a hearing. In March 2013, the Veteran testified before the undersigned at a Board hearing at the RO. A transcript of this hearing is also of record. Following the Board hearing, the Board remanded the matter to the agency of original jurisdiction (AOJ) in July 2013. It has now been returned to the Board for further appellate consideration. The Board takes notice that the Veteran's electronic claims file previously contained documents pertaining to a different Veteran. The misfiled documents, which consisted of the other Veteran's service treatment records, do not appear to have had an impact on any prior adjudication in the instant Veteran's appeal. In fact, on the Veteran's most recent supplemental statement of the case (SSOC), which was issued in August 2013, these misfiled documents were not listed as evidence. The misfiled documents have, therefore, been removed from the claims file for association with the correct claims file. Further remand in this regard is not necessary. FINDINGS OF FACT 1. Throughout the rating period under appellate review, beginning in May 2008 (exclusive of the period from July 1, 2009, until September 30, 2009, during convalescence for a surgical repair of a torn medical and lateral meniscus of the right knee), the Veteran's right knee disability, residuals of a right knee injury with degenerative joint disease, is shown to be productive of a disability picture that approximates no more than painful motion that is noncompensable in degree without recurrent subluxation or lateral instability. 2. Throughout the period of appellate review before the Board, the Veteran's right knee disability has also been manifested by meniscal problems consistent with a disability picture productive of cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. 3. The weight of the credible and most probative evidence of record makes it less likely than not that the Veteran's left knee condition, currently manifested by degenerative joint disease of the left knee; his bilateral hip disorder, currently manifested by degenerative joint disease; and his lumbar spine disorder, currently manifested by lumbar spine degenerative disc disease with herniated disc and left leg radiculopathy, were incurred coincident with his active duty service or were caused or aggravated by his service-connected right knee disability. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for the Veteran's right knee disability manifested by residuals of a right knee injury with degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.71a, Diagnostic Codes 5256-5257, 5259-5263 (2013). 2. The criteria for assignment of a separate 20 percent disability rating, but not more, for the service-connected right knee disability, as currently manifested by a meniscal condition status post meniscectomy, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5258 (2013). 3. The Veteran's current left knee disability was not was not incurred or aggravated by active service, or is proximately due to, or aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 4. The Veteran's current bilateral hip disability was not was not incurred or aggravated by active service, or is proximately due to, or aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 5. The Veteran's current lumbar spine disability was not was not incurred or aggravated by active service, or is proximately due to, or aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The VCAA, in part, 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, 5106, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The VCAA applies to the instant issues decided herein. Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information on how a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Here, regarding the duty to notify, the Veteran was sent a letter in June 2007 that provided information as to what evidence was required to substantiate the increased rating and service connection claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and effective date. In light of the June 2007 letter, which was sent prior to the December 2007 and February 2008 rating decisions now on appeal, no further development is required with respect to the duty to notify. Next, VA has a duty to assist a claimant in the development of a claim. This duty includes assisting in the procurement of service treatment records, all relevant pre-and post-service treatment records, and by providing an examination, when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. "Relevant records" in the context of VA's duty to assist "are those records that relate to the injury for which the claimant is seeking benefits and have a reasonable possibility of helping to substantiate the [] claim." Golz v. Shinseki, 590 F.3d 1317, 1321 (Fed. Cir. 2010) (quoting Black's Law Dictionary 1316 (8th ed. 2004), "defining 'relevant' as '[l]ogically connected and tending to prove or disprove a matter in issue; having appreciable probative value-that is, rationally tending to persuade people of the probability or possibility of some alleged fact.'"). Not all of a claimant's medical records will be relevant to a VA disability claim. Id. The Board finds that all necessary development has been accomplished in this case, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In particular, the claims file contains the Veteran's service treatment records, as well as all relevant post-service medical records available from VA and those private treatment providers identified by the Veteran. In addition to the documentary evidence, the Veteran's testimonial statements are of record, including testimony provided at two hearings before the Board. Importantly, these Board members, especially at the most recent hearing, identified the issues on appeal and suggested the submission of favorable evidence where necessary. The Board member particularly concentrated on eliciting testimony on those essential elements necessary to prove the claims. See Hr'g Tr. 6-8, 13, 19, 20. The Board member therefore satisfied all hearing officer duties as presently directed by 38 C.F.R. § 3.103(c). Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010); see also Procopio v. Shinseki, 26 Vet. App. 76, 80 (2012). Overall, the Board has carefully reviewed the medical records, plus the testimonial statements from the Veteran. This evidence reveals no additional relevant evidence available, such as medical records, that remains unaccounted for. In fact, more recently, the Veteran and his accredited representative were provided a SSOC in August 2013. This SSOC listed the most recent evidence used to decide the claim. The Veteran's representative responded later in August 2013 that they had no other more information or evidence to submit. Also, the Veteran was afforded several VA examinations, most recently in July 2013, to address the complex medical questions raised by this appeal. The Board finds that the VA examinations are adequate to decide the case because, as shown below, they were based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints. Further, the examinations describe the service-connected right knee disability, plus the claimed left knee, bilateral hip, and lumbar spine conditions in detail and sufficiently inform the Board of the examiner's judgment on those medical questions and the examiner's rationale for the opinions, which allows the Board to make a fully informed determination. See Monzingo v. Shinseki, 26 Vet. App. 97, 105 -06 (2012); Stefl v. Nicholson, 21 Vet. App. 123, 123 (2007). The Board accordingly finds no reason to remand for further examination. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the appeal. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Board finally finds that there was substantial compliance with the June 2013 Board remand directives. Specifically, the Veteran underwent adequate VA examinations in July 2013 to address the complex medical questions raised by the case and to evaluate the severity of the service-connected right knee disability, as directed by the Board. Then, these matters were readjudicated in an August 2013 SSOC, as directed by the Board. Accordingly, there was substantial compliance with the prior Board remand directives, and no further remand is necessary. See Stegall v. West, 11 Vet. App. 268 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to the internal medicine specialist requested by the Board). II. Analysis A. Increased Rating The Veteran is seeking a higher rating for his service connection right knee disability. Presently, the disability is assigned a single 10 percent rating. At his Board hearings on appeal, he testified that he had difficulty walking and climbing stairs, and he could no longer do any recreational activities such as play basketball or jog. He had pain "sometimes" for 8 to 10 hours per day. Also, his knee would lock "probably" 3 days per week, sometimes lasting 3 to 4 days until he could go see his doctor. He had not fallen, but had front-to-back instability, and he used cane and crutches "sometimes." He also testified that his knee affected his work. Initially, the Board notes that the instant appeal originally arose from a claim filed by the Veteran in May 2007. When this case was previously before the Board in July 2013, the Board decided a related issue concerning entitlement to restoration of a 20 percent disability rating for residuals of a right knee injury with degenerative joint disease, to include the propriety of the reduction for the period from May 1, 2008. The Board ultimately determined that the AOJ properly reduced the disability rating from 20 percent to 10 percent effective on May 1, 2008. In reaching this determination, the Board reviewed the evidence of record in light of the applicable diagnostic criteria, but determined that a rating higher 10 percent was not assignable. This included consideration of a separate rating for recurrent subluxation or lateral instability pursuant to DC 5257. Accordingly, the issue decided by the Board in July 2013 involved the same facts and law now before the Board. The Board's prior decision in July 2013 is final because the Veteran did not appeal it to the Court of Appeals for Veterans Claims (Court). Therefore, although the instant appeal arises from a May 2007 claim, the Board's July 2013 decision subsumes the period of appellate review prior to May 1, 2008. To now review the period prior to May 1, 2008, would require the Board to adjudicate the same issue based on the same factual basis. Such action is precluded by operation of law, absent a motion for revision of the decision based on clear and unmistakable error, which has not been filed in this case. See 38 U.S.C.A. § 7104; 38 C.F.R. §§ 20.1100, 20.1303; see, e.g., DiCarlo v. Nicholson, 20 Vet. App. 52, (2006); Hazan v. Gober, 10 Vet. App. 511, 521 (1997) (describing the law of the case doctrine). With this background in mind, the Board will first set forth the applicable law. Then, the Board will apply the facts of this case to the law to determine if a higher rating may be assigned for his right knee disability. 1. Applicable Law Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). The disability ratings are based primarily upon the average impairment in earning capacity resulting from a service-connected disability, that is, upon the economic or industrial handicap which must be overcome and not from individual success in overcoming it. 38 C.F.R. § 4.15 (2013). Where there is a question as to which of two disability ratings shall be applied, the higher disability rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2013). Otherwise, the lower rating will be assigned. Id. All potential applicable diagnostic codes, whether or not raised by a claimant, must be considered. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Furthermore, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the claimant. 38 C.F.R. § 4.3 (2013). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). A claimant, however, may experience multiple distinct degrees of disability, resulting in different levels of compensation, from the time the increased rating claim is filed to the time a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart, 21 Vet. App. at 510. An effective date may be assigned up to one year preceding the date of claim if the contemporaneous evidence shows that an increase in disability occurred during that time period. See Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010). If the increase in disability is shown to have occurred prior to that one-year period, an earlier effective date is not assignable one year prior to the date of claim. Id. Throughout the entirety of this period of appellate review, the Veteran's knee disability has been rated under diagnostic code (DC) 5010-5260. Disabilities of the knee are evaluated under the schedular diagnostic criteria set forth in 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5256 through 5263. The specific diagnostic criteria are as follows: Rating 5256 Knee, ankylosis of: Extremely unfavorable, in flexion at an angle of 45° or more 60 In flexion between 20° and 45° 50 In flexion between 10° and 20° 40 Favorable angle in full extension, or in slight flexion between 0° and 10° 30 5257 Knee, other impairment of: Recurrent subluxation or lateral instability: Severe 30 Moderate 20 Slight 10 5258 Cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint 20 5259 Cartilage, semilunar, removal of, symptomatic 10 5260 Leg, limitation of flexion of: Flexion limited to 15° 30 Flexion limited to 30° 20 Flexion limited to 45° 10 Flexion limited to 60° 0 5261 Leg, limitation of extension of: Extension limited to 45° 50 Extension limited to 30° 40 Extension limited to 20° 30 Extension limited to 15° 20 Extension limited to 10° 10 Extension limited to 5° 0 5262 Tibia and fibula, impairment of: Nonunion of, with loose motion, requiring brace 40 Malunion of: With marked knee or ankle disability 30 With moderate knee or ankle disability 20 With slight knee or ankle disability 10 5263 Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) 10 Under the rating schedule, normal range of motion of the knee for VA compensation purposes will be considered flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71a, Plate II. A separate, compensable rating(s) may be assigned under each of these three Diagnostic Codes (5257, 5260, 5261), if the specific symptoms are shown. See VAOPGCPREC 23-97; VAOPGCPREC 9-98; VAOPGCPREC 9-04. More generally, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see also Burton v. Shinseki, 25 Vet. App. 1, 5 (2011) (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). Moreover, when evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Burton, 25 Vet. App. at 5. Nonetheless, a rating higher than the minimum compensable rating is not assignable under any diagnostic code (relating to range of motion) where pain does not cause a compensable functional loss. The "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. This is because "pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss." Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). Finally, in making all determinations, the Board must also fully consider the lay assertions of record. If credible, 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). Thus, a layperson is competent to report on his symptomatology. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Moreover, lay evidence may be competent and sufficient evidence of a diagnosis or nexus if (1) the particular condition at issue is the type of condition that is within the competence or common knowledge of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana, 24 Vet. App. at 433, n.4. The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person. See Jandreau, 492 F.3d 1367-77; see also Kahana, 24 Vet. App. at 433 n.4. 2. Discussion Here, after carefully reviewing the pertinent evidence of record in light of the law set forth above, the Board finds that a rating higher than 10 percent is not warranted for his right knee disability as manifested by degenerative joint disease, but that a separate rating is warranted for a related meniscal condition, exhibiting symptoms to include cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. As described above, the period of appellate review within the Board's jurisdiction begins on May 1, 2008. Beginning May 1, 2008, the pertinent evidence of record shows that the right knee disability is not manifested by more than painful motion that is noncompensable in degree as set forth in the applicable diagnostic criteria of § 4.71a. More generally, the private and VA clinical records from July 2008 until a July 2013 VA examination show complaints of painful motion. Most of these medical records do not provide degrees of limited motion. For instance, he complained to his private doctor in December 2008 that his right knee "hurts." However, some of these records do indicate degrees of limited motion. First, his private doctor wrote in December 2008 that the knee "lacks about 2 [degrees] of full extension," and flexion was to approximately 120 degrees with "a lot of pain." A private May 2009 medical record similarly shows that the Veteran lacked "about 5 [degrees] of full extension"; flexion was to "about 115 [degrees] with pain." On follow-up in October 2009, it was found that the knee extended "fully." In April 2011, the private doctor, who noted that he had not seen the Veteran for two years, complained of right knee getting worse; his pain was "sometimes" severe. On clinical evaluation, the Veteran "lacked about 2 [degrees] or 3 [degrees] of full extension"; flexion was to "about 100 [degrees] with pain." In May 2011, this private doctor found range of motion from 7 degrees to 95 degrees. Finally on VA examination in July 2013, flexion was to 120 degrees, with pain starting at 110 degrees (unchanged after repetitive use testing); extension was to 0 degrees with pain (unchanged after repetitive use testing). This evidence does not demonstrate limited motion at a compensable degree (flexion limited to 45 degrees or extension limited to 10 degrees) as defined in 38 C.F.R. § 4.71a, DCs 5260-5261. To the contrary, interpreting the private medical records, flexion, in May 2011, was limited at its most severe to no more than 95 degrees, even taking into account motion limited by pain. Extension was limited to 7 degrees upon private evaluation in May 2011. These degrees of limited flexion and extension are noncompensable. See 38 C.F.R. § 4.71a, DCs 5260-5261. Consequently, the present 10 percent rating represents the higher schedular rating assignable for limited motion at this time. See Mitchell, 25 Vet. App. at 36 (quoting the Secretary's argument that "compensation for such pain (whether arthritic or nonarthritic) is limited to 10% per joint when there is 'no actual or compensable limitation of motion.'"); see also 38 C.F.R. § 4.71a, Plate II. The record also does not demonstrate more slight recurrent subluxation or lateral instability as set forth in 38 C.F.R. § 4.71a, DC 5257. Private evaluations in October 2008 and December 2008 indicate a finding of ligamentous instability. However, a private MRI in December 2008 revealed intact ligaments (ACL and PCL). Ligament testing (Lachman's test) in May 2009 and May 2011 was negative, and the joints "appear[ed]" stable in April 2011. Finally, the VA examination in July 2013 revealed normal stability testing with no patellar subluxation or dislocation. This evidence confirms two positive findings in October 2008 and December 2008, but otherwise stable right knee. The isolated findings are inconsistent with at least slight subluxation or lateral instability that is recurrent as required for a compensable rating under DC 5257. More importantly, as discussed in greater detail below, the Veteran has had ongoing meniscus (semilunar cartilage) problems rather than ligament problems. These problems manifest with complaints such as instability. To a lay person, including the Board, such evidence is indistinguishable between ligament and meniscus problems. The medical evidence, however, conclusively associates such symptoms with the Veteran's meniscus problems rather than a ligament condition. Accordingly, a higher or separate rating is not assignable under DC 5257 for recurrent subluxation or lateral instability. See 38 C.F.R. § 4.71a; Mittleider, 11 Vet. App. at 182; see also Jandreau, 492 F.3d 1367-77; Kahana, 24 Vet. App. at 433 n.4. In short, the evidence of record during the period of appellate review shows limitation of motion that is noncompensable. Importantly, the testing, including the private evaluations and VA examination, reflect the impact of pain on the Veteran's range of motion. Even taking his pain into account, the ranges of motion remained noncompensable. In other words, his pain does not result in an actual limitation more nearly approximating 45 degrees of limited flexion or 10 degrees of limited extension. 38 C.F.R. § 4.71a, DCs 5260-5261. Accordingly, neither a higher rating nor a separate compensable rating is assignable, even when taking into consideration the Deluca factors, under DCs 5260 and 5261. Likewise, the evidence does not show at least slight recurrent subluxation or lateral instability, under DC 5257. It is VA's established policy to assign a single 10 percent rating in these situations where there is no actual or compensable impairment other than painful motion. See, e.g., Mitchell, 25 Vet. App. at 36. Notwithstanding the above determination, the Veteran has been assigned a temporary total (100 percent) rating under 38 C.F.R. § 4.30, from July 1, 2009, until September 30, 2009, during his convalescence following a surgical repair of a torn medial and lateral meniscus of the right knee. The surgery involved partial medial and lateral meniscectomies, plus a chondroplasty of the patella femoral joint. The Board now finds that a separate 20 percent rating is warranted under DC 5258, both prior to and following this period of convalescence due to ongoing symptomatology involving cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint, as set forth in 38 C.F.R. § 4.71a, DC 5258. Specifically, a private evaluation in July 2008 shows positive crepitus, and X-rays in October 2008 demonstrated mild joint effusion. In December 2008, the Veteran complained of right knee hurting with giving way with pain and swelling; an MRI was performed, which confirmed tearing of the menisci. On follow-up later in December 2008, the Veteran again reported problems with standing and walking; even small amounts of twisting caused him significant pain. On further consultation in May 2009, the private doctor found torn lateral meniscus with a tendency to give way, but no recent fall or trauma. Accordingly, he underwent surgery in early July 2009. After the convalescent period ended in September 2009, the medical records are silent until April 2011, when the same private physician noted that he had not seen the Veteran for two years. At that time, the Veteran complained of a tendency for the knee to lock, especially when standing and exercising; the pain was sometimes severe, and sometimes it tended to swell. Physical examination showed tenderness and effusion. The Veteran had similar complaints on follow-up in May 2011, June 2011, July 2011, August 2011, February 2012, including locking. However, physical examination in May 2011 found no effusion or swelling, and meniscus testing (McMurray's test) was negative. Notwithstanding the negative finding in May 2011, the July 2013 VA examination again demonstrated positive McMurray's testing, and the examiner concluded that the Veteran's meniscal condition now resulted in degenerative joint disease (DJD), pain, (non-painful) scar, swelling, limp, and crepitus. In light of the demonstrated symptomatology, a 20 percent rating is assigned under DC 5258. Otherwise, the evidence does not demonstrate ankylosis of the knee; symptomatic removal of semilunar cartilage; impairment of the tibia and fibula; or genu recurvatum. A September 2008 evaluation showed minor patella spurring, consistent with the December 2008 MRI demonstrating tibial arthritis with cartilage irregularity, small osteophytes, mild diffuse irregular signal within patellar cartilage; and mild patellar and quadriceps tendinosis. And, as previously noted, he underwent chondroplasty of the patella femoral joint at the July 2009 surgery. Thus, there is some involvement of the tibia. However, the evidence shows that this does not result in nonunion or malunion. Accordingly, a compensable rating in this appeal is not warranted under DCs 5256, 5259, 5262, or 5263. 38 C.F.R. § 4.71a; see Schafrath, 1 Vet. App. at 595. Further, although the July 2013 VA examination confirms a scar at the site of the Veteran's last surgery, it was not painful and no other abnormality was associated with the scar. Accordingly, a separate rating is not assignable for the scar. 38 C.F.R. § 4.118. In reaching this determination, the Board has carefully considered the Veteran's own assertions, including his Board hearing testimony. Specifically, he most recently informed the July 2013 VA examiner that he used a brace and occasionally needed his spouse to assist with putting on his shoes and socks. He also reported that his job was limited due to limits on bending, stooping, crawling, climbing, heavy lifting, and other activities. Further, he was limited to walking one quarter of a mile, and standing was limited to 10 minutes. However, he acknowledged that his activities of daily living were generally not limited, although he did go at a slower pace. His statements are consistent with the remaining evidence showing such symptoms as pain, locking, and a feeling of instability. As discussed, his disability picture presents a complex medical question concerning what degree of symptomatology is represented by what anatomical component of the knee joint. Such a question is not within the common knowledge of a lay person, and the Veteran has not demonstrated any degree of competence, either through education or experience, to competently inform this question. In other words, the Veteran's own statements are insufficient to attribute any degree of functional limitation to the various pathologies in his knee. See Jandreau, 492 F.3d 1367-77; see also Mittleider, 11 Vet. App. at 182. Nonetheless, his testimony has more fully informed the Board's determination as to the functional impact of his overall disability picture, and the ratings assigned are intended to adequately compensate his day-to-day impaired functionality. For the foregoing reasons, an increased rating in excess of 10 percent for degenerative joint disease of the right knee is denied. However, a separate 20 percent rating is warranted under DC 5258. These ratings represent, and compensate, the Veteran for his entire service-connected right knee disability picture as currently demonstrated. See Mittleider, 11 Vet. App. at 182. "Staged ratings" are not warranted because the schedular criteria for the assigned ratings were met throughout the entire time during the period under appellate review. See Hart, 21 Vet. App. at 505; Fenderson, 12 Vet. App. at 126-27. Extraschedular Consideration The Board's findings above are based on schedular evaluation. Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Schedular ratings are based primarily upon the average impairment in earning capacity, that is, upon the economic or industrial handicap which must be overcome and not from individual success in overcoming it. 38 C.F.R. § 4.15. To afford justice in exceptional situations, however, an extraschedular rating may also be assignable. 38 C.F.R. § 3.321(b). The Board may not, in the first instance, assign an increased rating on an extraschedular basis, but may determine whether referral for extraschedular consideration is warranted, provided that it articulates the reasons or bases for that determination. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). This determination follows a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, the level of severity and symptomatology of a veteran's service-connected disability must be compared with the established criteria found in the rating schedule for that disability. Id. If the rating criteria reasonably describe a veteran's disability level and symptomatology, the disability picture is contemplated by the rating schedule. Therefore, the assigned schedular evaluation is adequate and no referral is required. Id. If the schedular evaluation does not contemplate the level of disability and symptomatology, and is found inadequate, the second step of the inquiry requires the Board to determine whether the exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-16. The first two steps should be undertaken by comparing the disability picture of each service-connected disability with the criteria in the rating schedule for that disability. The Board should compare the service-connected disability picture with the criteria in the rating schedule for that disability. Johnson v. Shinseki, 26 Vet. App. 237 (2013). Extraschedular consideration is undertaken on the basis of each individual service-connected disability. Based on this disability-by-disability approach, the Board is not required to consider whether a veteran is entitled to referral for extraschedular consideration of his service-connected disabilities on a collective basis. Id. If analysis of the first two steps shows that the rating schedule is inadequate to evaluate the disability picture and that picture shows the related factors discussed above, the final step requires that the disability be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. at 116. Here, the Board finds that referral for extraschedular consideration is not warranted. As discussed above, the Veteran's disability picture consists of arthritis with limitation of motion, and a meniscus condition, which contributes to his decreased functionality and gives him a feeling of instability. This prevents him from engaging in some former activities, such as jogging and playing basketball. Even accepting his statements as entirely competent and credible, the Board finds that the rating criteria reasonably describe his disability level and symptomatology. Although the rating criteria do not exactly consider such factors as an inability to jog or play basketball, the rating criteria do compensate him for the painful motion and other symptoms triggering these reduced activities. In fact, his overall symptomatology represents the expected and most commonly seen disability picture in claimants with his degree of knee impairment. To state this slightly differently, his case does not present a disability picture that is exceptional or unusual from that commonly presented to the Board. Accordingly, the Veteran's disability picture is reasonably contemplated by the rating schedule, and the assigned schedular evaluation is adequate, and no referral for extraschedular consideration is required. 38 C.F.R. § 3.321(b); Thun, 22 Vet. App. at 116. B. Service Connection The Veteran is also seeking service connection for a left knee condition, a right and left (bilateral) hip condition, and a low back (lumbar spine) condition. He presents two alternative theories of entitlement in support of these claims. First, alleges that each disability had its onset directly during service (commonly referred to as "direct" service connection). Specifically, in a July 2007 statement, the Veteran wrote that he had continuous problems, that is chronic pain, in his back, knees, and hips beginning from 1976. He stated that his back problem started around 1977, and had progressed since then. Alternatively, he contends that each of these conditions is caused or worsened by his service-connected right knee disability (commonly referred to as "secondary" service connection). Because the law and facts regarding each theory of service connection is different, the Board will discuss them separately. 1. Direct Service Connection Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection generally requires evidence satisfying three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013). Certain chronic diseases, which are listed in 38 C.F.R. § 3.309(a), including arthritis, may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Id. However, if chronicity in service is not established or where the diagnosis of chronicity may be legitimately questioned, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). A claimant "can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in § 3.309(a)." Walker, 708 F.3d at 1337. Service connection may nonetheless be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). If there is conflicting medical evidence on any element material to the claim, the Board may not ignore or disregard any medical professional's opinion, but may assign greater probative to one medical opinion over by providing an adequate statement of reasons or bases for doing so. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Willis v. Derwinski, 1 Vet. App. 66, 70 (1991). A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board must also fully weigh the probative value of the lay evidence of record against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012). The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person. See Jandreau, 492 F.3d 1367-77; see also Kahana, 24 Vet. App. at 433 n.4. A veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009); see also Walker, 708 F.3d at 1334. But, a veteran must be given the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § 5107(b)). Here, the Board finds, after careful consideration of the record, that the preponderance of the more probative evidence weighs against the direct service connection claims, for the following reasons. a. Existence of a Present Disability The evidence of record confirms the existence of the claimed conditions. Specifically, a VA examiner in July 2013 made a diagnosis of DJD of the left knee; bilateral hip DJD; and lumbar spine degenerative disc disease (DDD) with herniated disc (and left leg radiculopathy). These facts are not materially in dispute. Thus, the evidence established that the Veteran has a current disability. b. In-Service Incurrence or Aggravation of a Disease or Injury Left Knee The Veteran's service treatment record (STR) shows treatment for left leg injuries, but does not does not reveal any abnormality or impairment associated with the left knee. More specifically, in July 1977, he presented for pulled muscle in the leg (although the specific leg is not identified and the Veteran did not wait to be seen). He was also seen in September 1977 for complaints associated with being kicked in the left thigh (a diagnosis was not made). Later in September 1977, he was involved in a motor vehicle accident (MVA), which resulted in tenderness and abrasions, including on the left lower leg. But, he had full range of motion of the knee. (For sake of reference, the Board notes that this MVA directly resulted in the eventually grant of service connection for the right knee disability discussed above.) Approximately one year later, in September 1980, the Veteran sought treatment for pain in the left leg, which he had injured the day prior while playing basketball. Physical examination showed muscle very tense and tight, and the assessment was "pulled muscle." Then in June 1981, the Veteran "c[omplained of] knee pain" with a "past history of knee problems, " including a motorcycle injury in 1979. Most recently he "[f]ell on [the] knee last week." (The knee injured is not identified.) Next, he underwent an orthopedic consultation in February 1982. The referral indicates that the Veteran complained of intermittent "(L)" knee pain for 4 months, with a history of trauma in December 1970, the MVA. The provisional diagnosis was "(R)" knee impairment. Finally, on discharge in April 1982, a physical examination of the lower extremities was normal, and the Veteran had no complaints except for the right knee. To summarize, these STRs do not indicate a left knee condition. To the contrary, they show extensive entries related to the right knee. Although the June 1981 record does not identify the knee involved, and the February 1982 referral form first indicates the left knee, it is clear from the context of the records that only the right knee was involved. Importantly, all of these records refer to a "knee" (singular) impairment. Moreover, they consistently note the history of injury during the MVA, which undisputedly involved the right knee. He also had left leg injuries, but no indication of knee involvement. The Board finds that a left knee injury, if present, would have ordinarily been recorded in the medical records in some manner, if such existed. In other words, the Veteran's other injuries, however authentic, are extensively documented in the STRs. However, a left knee injury is not. It is within the common knowledge of a law body, such as the Board, to assume that a left knee injury would be recorded in the STRs, if present. Therefore, the absence of a documented left knee injury makes it is less likely that the knee injury actually occurred. See AZ v. Shinseki, No. 2012-7046, 2013 WL 5420978, at *12, (Fed. Cir. Sept. 30, 2013); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); see also Kahana, 24 Vet. App. at 440 (2011) (Lance, J., concurring) (citing Buczynski, 24 Vet. App. at 224; Fed. R. Evid. 803(7)). Any assertions to the contrary are more likely consistent with an inaccurate recollection or a direct misrepresentation. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd 78 F.3d 604 (Fed. Cir. 1996). In fact, a contemporaneous statement as to a declarant's then-existing physical condition, such as his separation examination, (as opposed to his current statements of memory or belief to prove the fact remembered or believed) is recognized as possessing circumstantial guarantees of trustworthiness. See Fed. R. Evid. 803(3). Therefore, the separation examination must be accepted as the credible and accurate account of his knee condition during service. In either event, the credible evidence does not establish an in-service left knee injury or disease. Left and Right Hip As with the left knee, the STRs also do not demonstrate an injury or disease involving the left or right hip. Importantly, the Veteran underwent an extensive evaluation after the September 1977 MVA, but there was no tenderness over the pelvis or thighs, and he had full range of motion of the hips. Also during service, he was treated in July 1979 for an infect wound on the right thigh, and again in March 1982 for an abscess in the right thigh. Again, it does not take any specialized knowledge or training to understand in this case that a hip condition, whether injury or disease, would be documented in some manner in the STR if extant. Therefore, the absence of a documented hip condition or injury makes it is less likely that a hip injury or condition actually occurred during service. See AZ, No. 2012-7046, 2013 WL 5420978; Buczynski, 24 Vet. App. at 224; see also Kahana, 24 Vet. App. at 440 (2011) (Lance, J., concurring) (citing Buczynski, 24 Vet. App. at 224; Fed. R. Evid. 803(7)). Any assertions to the contrary are more likely consistent with an inaccurate recollection or a direct misrepresentation. See Caluza, 7 Vet. App. at 510-11. In fact, a contemporaneous statement as to a declarant's then-existing physical condition, such as his separation examination (as opposed to his current statements of memory or belief to prove the fact remembered or believed), is recognized as possessing circumstantial guarantees of trustworthiness. See Fed. R. Evid. 803(3). Therefore, the separation examination must be accepted as the credible and accurate account of his hip condition during service. In either event, the credible evidence does not establish an in-service injury or disease involving the left hip or right hip. Low Back In contrast to the left knee and hips, the STRs include extensive entries related to the low back. Specifically, the STR shows complaints in November 1976 of low back pain for 3 days with no known injury; the assessment was muscle spasm. Then, in January 1977, he again presented for treatment with complaints of low back pain. He reported that the first episode occurred in November 1976 while in basic training, when "he lifted something heavy," and the pain returned the prior Friday while cleaning his locker. X-rays were "Neg[ative]" at that time, including negative straight leg raise (SLR) testing. Following this treatment, the Veteran was seen 4 times throughout the remainder of January 1977 for complaints of back pain diagnosed as acute back strain. He was then seen twice in February 1977, and once in March 1977, again for back pain diagnosed as lumbar strain. An assessment of "MLBS" was made in April 1977, although this acronym is undefined. He was then seen for mechanical low back pain in September 1977 with a notation that he was "very dramatic" upon evaluation. He was put on physical profile. The next day, he again complained of back pain, which was noted as "subjective" with no objective findings. The assessment was "? malingerer." Two days later in September 1977, he was involved in the MVA, where he was a passenger in a car. It was noted that he was "obviously intoxicated," with multiple abrasions, including on the left lower leg. No abnormality is documented referable to the low back. A physical therapy record from September 1977, shows complaints of low back pain [unreadable], increased when sitting. The Veteran "state[d] that he has been having low back pain of[f] and on since May 1977." But, the physical therapist found that "it was not possible to detect any muscle spasms" due to the Veteran "twisting and turning though palpation was done rather more gently than other p[atients]." In October 1977, the physical therapy was discontinued after 4 treatment because the Veteran "appears to be feeling very well." Nearly one year later, in August 1978, the Veteran again sought treatment for low back pain. On consultation, it was noted that he had a negative attitude towards treatment for a back problem. He stated it has lasted for 2 years. During a further consultation later in August 1979, it was noted that he had low back pain with no knowledge of being hurt, but had chronic back pain for 2 years, recent episode began 3 days ago. The assessment was mechanical LBP, "malingerer !". The next day, he presented to the emergency room for complaints of low back pain that were found to be "out of all proportion to physical findings," and the assessment was again "malingerer." In April 1982, the discharge clinical evaluation revealed normal spine, and the Veteran had no complaints except for the right knee. The Board finds that these STRs show complaints and treatment for the low back. Importantly, however, the STRs themselves call into question the accuracy and veracity of the Veteran's complaints. Again, the separation examination must be accepted as the credible and accurate account of the condition of his back during service. c. Nexus The evidence finally shows that it is less likely than not that the current left knee, bilateral hip, and low back conditions are were incurred directly during service. Importantly, the current diagnoses of DJD of the left knee and hips, in addition to DDD of the lumbar spine, are consistent with "arthritis," which are chronic disease listed in 3.309(a). However, neither DJD of the left knee or DJD of the hips was actually established during service, and the fact of chronicity during service is not otherwise supported. 38 C.F.R. § 3.303(b). To the contrary, as explained immediately above, the most probative evidence makes it less likely that the Veteran suffered any in-service incurrence of injury or disease in these joints. Similarly, because the conditions are not noted during service in any manner, a showing of continuity of symptomatology may not support the claims. See 38 C.F.R. § 3.303(b) (requiring a showing of continuity of symptomatology after service for any chronic condition "noted," but not established as chronic, during service). The Veteran's own statement currently indicating a continuity of symptoms after service do not inform this question, and are not credible in light of the absence of such evidence during service. See id. Although the Veteran may have had back pain during service, this manifestation alone does not permit a finding of chronicity for arthritis, which is first shown as a clinical entity, DDD with herniated disc, at a much later date. See id. As such, a showing of continuity after discharge is required to support the claim. See id. He has not specifically alleged a continuity after discharge. Accordingly, his statements have no evidentiary value to support a finding of continuity after discharge. In short, these claims may not be granted on the basis of chronicity or continuity pursuant to 38 C.F.R. § 3.303(b). Without regard to the specific chronicity and continuity requirements set forth in 38 C.F.R. § 3.303(b), the remaining evidence shows that none of these conditions was ongoing after service. To the contrary, the Veteran filed an original service connection claim in August 1988. At that time, he claimed disability in the right knee, but no other joint condition. It is expected that if he had a left knee, hip, or low back condition at that time, which he felt to be directly related to service, he would have claimed it as well. See, e.g., AZ, No. 2012-7046, 2013 WL 5420978, at *12. Because he did not, this is makes his later assertions to the contrary noncredible statements more consistent with his desire to present his case in a light most favorable to his claim, without regard to accuracy. Furthermore, the Veteran underwent a complete general VA examination in 1989 connection with his original claim. Importantly, the VA examination was not limited to the right knee. Thus, it is directly relevant here. With this in mind, the Board observes that the review of systems was "neg[ative] except for arthritis problem" in right knee, and the diagnosis was "none," normal general examination. More recently, with specific regard to the left knee, a private X-ray in August 2002 notes a clinical history of chronic medial knee pain (where the knee involved is not identified), but there was no radiographic abnormality of the left knee. Then, on private consultation in September 2004, the Veteran complained of left knee pain for 2 to 3 weeks, although it is noted that the had a history of DJD in the "knees." Also indicating a more recent onset, the Veteran underwent a private consultation in June 2011. The Veteran, at that time, gave a history of pain beginning in 2010. He underwent a VA joint examination in November 2007. On the same day, he was also examined for the low back (discussed in greater detail below). He gave a history of low back pain present for 20 years, but did not offer a similar history for either hip or knee. In fact, at that time, he gave a history of left knee bothering him for only the last 3 years. This discrepancy between the back and hips and knees calls into question the accuracy of his current assertions to the contrary. In other words, it is expected that he would have made similar statements for all disabilities, rather than just the back, if such symptoms had been present for 20 years. Moreover, although the Veteran reported low back pain since service, the credibility of his own statements to the November 2007 VA examiner is questionable in light of the multiple assessment during service that his complaints represented "malingering." The intervening VA examination in September 1989 also contradicts his present assertions. Furthermore, he was involved in another MVA in February 2011. On subsequent evaluation, he gave a history of only 1 week of low back pain. Then, in July 2012, a private consultation reflects back pain occurring without any known injury, although "[t]he injury involved the lower back" 3 days ago where "[o]nset was immediately after the injury." The Veteran was then seen for complaints of low back in August 2012, and subsequent evaluations in September 2012, October 2012, and April 2013, all show that he complained of acute onset of low back pain radiating into his calf since August. It was noted that the initial onset resolved until he went with his children and then it returned with "a vengeance [sic]." Most significantly, it was noted that "he does not have a history of previous back pain . . . " (emphasis added). This evidence, in summary, establishes that it is less likely than not that the Veteran had ongoing left knee, hip or low back problems after service. Even should the Veteran's allegations of ongoing symptoms after service be credible, however, his lay statements are outweighed by the more probative evidence, particularly a July 2013 VA examination, establishing that a relationship between his symptoms and the current condition is unlikely. The record on appeal includes conflicting opinions directly addressing whether the left knee condition was incurred in service. Favorable to the claim, a private orthopedic surgeon wrote a letter in support of the claim in May 2011. He noted that the Veteran described his right knee injury during service, but also gave a history of "[i]n the interim, he has also been complaining of the onset of left knee pain which was secondary to overuse due to the prior right knee problems," and "[h]e was given a return to duty in 1980." After then noting the results of the clinical evaluation and diagnostic testing, the physician gave a diagnosis of osteoarthritis, greater than left. Finally, he offered his "strong opinion that the present knee condition is direct causally related to the prior injury which this patient sustained while on active duty . . . in April 1980 after being involved in a motorcycle accident." He explained that he had "reviewed this patient's prior military records for his orthopedic complaints and the orthopedic consultation [during service] dated April 2, 1980." The Board finds that this May 2011 medical opinion must be assigned limited probative weight. First, the accurateness of his factual background is called into question when taking into consideration his next treatment record, dated in June 2011, specifically noting "obtain prior military [sic] records." It is therefore unclear if the physician had any STRs other than the April 1980 orthopedic consultation when he gave his opinion. In fact, it would appear he did not, especially when he based his opinion on an injury sustained at the time of the MVA, even though the STRs show that he did not suffer a left knee injury at that time (or any other) during service. Also significant, the physician did not explain why or how he reached his determination. Although the Board might be able to infer his underlying reasoning based on an overall reading of the report, without an accurate factual background, the Board can ultimately assign no evidentiary weight to this opinion. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (explaining that an examination report "must be read as a whole" to determine the examiner's rationale). The private examiner did not offer an opinion as to the hips or low back. The Veteran has also offered his own opinion relating his claimed conditions to service. Notwithstanding the questionable credibility of his assertions overall, the Board finds that the specific medical question at issue here falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4; Kahana, 24 Vet. App. at 435. In fact, it is the subject of advanced medical knowledge concerning complex biological processes, anatomical relationships, and physiological functioning involving the knee, hips, and low back. Thus, it is not within the competence of a lay person such as the Veteran. In short, while the record before the Board includes a medical opinion relating a current left knee condition to service, plus the Veteran's own opinion relating all of his claimed conditions to service, those opinions are of little to no probative weight in informing the question of direct causation in this case. Weighing against these favorable opinions, the Veteran underwent a VA examination in connection with the instant appeal in November 2007. At that time, he gave a history of left knee bothering him for the last 3 years. The VA examiner opined that the Veteran's left knee disorder is less likely than not related to his right knee condition. He explained that DJD is an aging process and does not have anything to do with his right knee condition. The Board finds that this VA examiner's opinion is evidence weighing against the direct theory of entitlement. Specifically, the examiner attributed the Veteran's left knee condition to the "aging process." By inference, this would rule out that the condition was due to any event or injury but the aging process. However, because the VA examiner did not directly state this conclusion or articulate his supporting rationale, the Board finds that the November 2007 VA examiner's opinion has little probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. More conclusively, the Veteran underwent a second VA examination in July 2013. This VA examiner correctly noted that there is no evidence for treatment of a left knee or other condition during the Veteran's service. The examiner made clear that "[t]he record is silent," including the separation examination, which was negative for any left knee or hip abnormality. The examiner also correctly noted that there was no interim data proximate to discharge. Next, the examiner stated his opinion that "the current left knee condition is not directly related to [the Veteran's] military service." He also opined that "[b]ased on the data data available," it was his opinion "that the current bilateral hip conditions are not directly related to service." With regard to the low back, the VA examiner noted the Veteran's complaints of low back pain during service. The VA examiner also cited the specific treatment records during service. The examiner determined, however, that he was last treated during service in August 1979 for an acute condition, and then served an addition 2 years and 9 months without any further care or complaints. Accurately, the VA examiner noted that the separation examination was negative for any spine abnormality. The VA examiner determined that the remaining medical visits during service showed no indication of any disc condition, degenerative condition, or radicular symptoms. Rather, according to the VA examiner, he had "essentially normal" examinations with some complaints of pain. The examiner also cited the indications of exaggeration and malingering during service. The examiner found no evidence proximate to discharge. Based on this foundation, the VA examiner opined that the current low back condition is less likely than not related to the complaints shown during service, and is less likely than not related to service. The Board observes that the VA examiner did not expressly articulate the connection between the facts cited and the opinion given regarding the left knee. Nonetheless, reading the opinions as a whole, particularly in light of the opinion regarding the hips and back, the examiner's underlying rationale is clearly based on the inductive reasoning that without any evidence of a condition during service, a current disability may not be medically associated with the current disability. The Board, in its lay capacity, is not able to question the examiner's medical judgment, nor does it find any reason to do so. To the contrary, the July 2013 VA examiner's opinion is factually accurate, unequivocal, and sufficiently supported. Accordingly, it is highly probative and assigned great evidentiary weight. See Nieves-Rodriguez, 22 Vet. App. at 304; Monzingo, 26 Vet. App. at 107. In light of the foregoing, with careful consideration of the relative probative value of the unfavorable evidence, which is considerable, with that of the favorable evidence, which is minimal, the Board finds that the preponderance of the most probative evidence of record weighs against the claims of service connection on a direct basis. In other words, the favorable evidence is insufficiently probative to bring the record into a state of relative equipoise when considering the highly probative unfavorable evidence of record on the direct theory of service connection. 2. Secondary Service Connection Service connection may be granted for a disability that is proximately due to or the result of a service-connected disability, which includes the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Aggravation, per VA regulation, is defined in this context as any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. 38 C.F.R. § 3.310(b). To establish 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 connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). (The Board notes that VA amended its regulation pertaining to secondary service connection, effective from October 10, 2006, which was prior to when the Veteran filed his instant claim in 2007. See 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310). As the instant appeal was filed after October 2006, the current version of the regulation applies here.) Here, the record before the Board, as specified above, confirms the existence of the claimed disabilities. Moreover, the Veteran is currently service-connected for a right knee disability. These two facts, the existence of a current disability and a service-connected disability, are not materially in dispute. Consequently, the central question for resolution on this secondary theory of entitlement is whether a nexus exists between the current disabilities and the service-connected disability. On this question, the pertinent evidence predominantly weighs against the claim. As detailed above, a private physician wrote a letter in May 2011 to support the claim. He opined that "the left knee condition is directly causal and consequential to the right knee progressive condition." The Board again finds, for the same reasons discussed herein above, that this May 2011 opinion, while probative, must be assigned very low weight. First, it appears from this physician's clinical records, which are in the claims file, that he had been treating the Veteran since at least 2011. This background undoubtedly informed his favorable nexus opinion. Notwithstanding his treatment history, the physician did not cite any supporting evidence except for the Veteran's own statements that he "complain[ed] of the onset of left knee pain which was secondary to overuse due to the prior right knee problems." Moreover, it is not clear (in comparison with the July 2013 VA examination), that this physician otherwise accurately reviewed the pertinent medical history. As described above, the contemporaneous records contain specific clinical and diagnostic examination results, which are material to the medical question presented, but which do not appear to have been conveyed by the Veteran. In other words, this physician relied solely on the Veteran's own assertions, which means he reasoned from an incomplete factual premise. See, e.g., Kahana, 24 Vet. App. at 439 n. 8 (Lance, J., concurring) (distinguishing an incorrect factual premise, which has no probative value, from an incomplete factual premise). More importantly, the physician did not articulate the reasons underpinning his opinion. The Board could attempt to infer his rationale by reading the opinion as a whole. This would not increase the probative weight of the opinion, however, because the VA examiner could only have reasoned from his own incomplete understanding of the Veteran's history. In other words, the opinion is based on an incomplete factual premise, which renders the opinion and any supporting rationale unfounded. Accordingly, this opinion must be afforded materially limited probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The Veteran has also offered his own opinion relating his claimed conditions to the right knee disability. Even if his statement be found credible, the Board finds that the medical question here involving secondary causation (and aggravation) falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4; Kahana, 24 Vet. App. at 435. To the contrary, it is the subject of advanced medical knowledge concerning complex biological processes, anatomical relationships, and physiological functioning involving the knee, hips, and low back. Thus, it is not within the competence of a lay person such as the Veteran. He also testified at his Board hearing that his doctors have verbally told him that his left knee problems are due to overcompensation from his right knee problems, and that his hip condition "stem[s] from" his legs. Hr'g Tr. 11-12. Medical opinions, such as these, which are submitted into evidence via a lay person rather than directly from the medical professional, are, as a general matter, admissible. See Robinette v. Brown, 8 Vet. App. 69, 74 (1995). The Board must, however, assign this testimony, and the underlying medical opinions, limited probative weight for three related reasons. First, as discussed above, the Veteran is an unreliable historian, which makes his testimony of questionable accuracy and without any guaranty of trustworthiness. The second reason is that, even if accurately relayed, the Board is unable to determine the completeness and/or accuracy of the factual foundation underlying these favorable nexus opinions. Third, and finally, the Board is unable to assess the soundness of the rationale underpinning the opinions. In light of these three weaknesses, the Board can assign no more than nominal probative value to these medical opinions relayed by the Veteran. See, e.g., Nieves-Rodriguez, 22 Vet. App. at 304; Monzingo, 26 Vet. App. at 107; see also Kahana, 24 Vet. App. at 433. In short, while the record before the Board includes the May 2011 private medical opinion relating the current left knee condition to the right knee condition, plus the Veteran's own opinion relating all of his claimed conditions to service, plus the verbal opinions of his doctors, this evidence is of slight probative weight in informing the question of secondary causation in this case. In comparison with this favorable evidence, the record contains highly persuasive unfavorable evidence. Specifically, the Veteran under two VA examinations which are of much greater probative value. First, he was examined by VA in November 2007. As above, the VA examiner opined that the left knee, bilateral hip, and low back disorders are less likely than not related to his right knee condition. The examiner explained that DJD is an aging process and does not have anything to do with his right knee condition. More recently, he was examined in July 2013. On the secondary theory of entitlement, the VA examiner opined that the current left knee condition is "not secondary to" and is "not aggravated (as defined for VA purposes) by the right knee condition." The examiner reasoned that there is nothing in the currently accepted, peer reviewed, credible, and authoritative orthopedic literature that demonstrates that an intrinsic condition of a knee with or without altered gait and/or with or without surgical intervention will cause or aggravate intrinsic conditions of the contralateral knee. The examiner also "finds no evidence of aggravation." The examiner provided materially identical opinions with respect to the spine and hips. The Board finds that this July 2013 VA examiner's opinions are highly probative evidence weighing heavily against the secondary theory of entitlement. First, the opinions were informed by the examiner's exhaustive review of evidentiary record. Because this July 2013 VA examination report contains detailed historical, medical facts, this review heightens the probative value of the examiner's opinion. Further, the examiner reviewed the medical literature. This effort indicates that the examiner sought objective and impartial information, but found none. Again, this degree of research heightens the probative value of the examiner's opinions. Also, the examiner gave specific and unequivocal opinions. Finally, the examiner articulated the medical reasoning underpinning the opinions. Consequently, while unfavorable, the Board is convinced that the VA examiner's opinions are independent and impartial. Moreover, because the examiner's opinions are opinions are fully articulated with clear conclusions based on an accurate factual foundation and are supported by sound reasoning, the opinions are of determinate probative value. Overall, with careful consideration of the relative probative value of the unfavorable evidence, which is considerable, with that of the favorable evidence, which is minimal, the Board finds that the preponderance of the probative evidence of record weighs against the claims of service connection. Consequently, it is less likely than not that the left knee condition, a hip condition, or a low back condition is secondary to the service-connected right knee disability. In reaching the above conclusions, including both theories of service connection, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence on either theory of entitlement. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § 5107(b)). ORDER A rating in excess of 10 percent for degenerative joint disease of the right knee is denied. A separate rating of 20 percent for meniscal tear, status post arthroscopy, is granted, subject to the rules and regulations governing the payment of VA monetary benefits. Entitlement to service connection for a left knee disorder is denied. Entitlement to service connection for a bilateral hip disorder is denied. Entitlement to service connection for a lumbar spine disorder is denied. ____________________________________________ Paul Sorisio Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs