Citation Nr: 1337414 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 10-35 161 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for a left knee disorder. 3. Entitlement to service connection for a right knee disorder. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD T. Hal Smith, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002 & Supp. 2012). The Veteran served on active duty from April 1977 to September 1979. These matters are before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of the Waco, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA). In pertinent part, that decision denied service connection for tinnitus and for bilateral knee disorders. The current claims were remanded in May 2012 and April 2013 for additional development, and they have now been returned for further appellate consideration. During the pendency of this claim, service connection was established for bilateral hearing loss in the April 2013 Board decision mentioned above. The following determinations are based on review of the Veteran's claims file in addition to his Virtual VA "eFolder." FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, his tinnitus is related to service-connected bilateral hearing loss. 2. The Veteran's credible statements regarding his clinical history of left knee symptoms presented at enlistment and subsequent report of pre-service left knee recurring effusion with meniscectomy, in the context of the contemporaneous clinical record, obviously or manifestly establishes that a chronic left knee disability preexisted his entry into active service in April 1977. 3. The Veteran's preexisting left knee disorder, effusion of the left knee resulting in a meniscectomy, obviously or manifestly did not undergo a permanent worsening beyond its normal clinical progression during active military service. 4. A chronic right knee disability, currently diagnosed as degenerative joint disease (DJD), was not present in service or until years thereafter and is not etiologically related to any incident of active duty service. CONCLUSIONS OF LAW 1. Tinnitus is secondary to service-connected bilateral hearing loss. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 2. The presumption of soundness regarding the state of the Veteran's left knee at the time of his entry into active duty in April 1977 has been rebutted by clear and unmistakable evidence, and the left knee disorder was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1111, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.304(b) (2012). 3. A right knee disability, currently diagnosed as DJD, was not incurred in or aggravated by active service, nor may its incurrence or aggravation be presumed. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist In November 2000, the Veterans Claims Assistance Act of 2000 (VCAA) was signed into law. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify him what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c) (2012). Subsequent judicial decisions have clarified the duties to notify and assist imposed by the VCAA, to include Pelegrini v. Principi, 18 Vet. App. 112 (2004), Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 ((Fed. Cir. 2006), and Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As to the claim for service connection for tinnitus, in light of the above-noted legal authority, and in light of the Board's favorable disposition of this matter, the Board finds that all notification and development action needed to fairly resolve the claim has been accomplished. As to the claims for service connection for bilateral knee disorders, first, VA has a duty under the VCAA to notify a claimant and any designated representative of the information and evidence needed to substantiate a claim. In this regard, letters to the Veteran from the RO (to include letters in October 2008, May 2012, February 2013, and April 2013) specifically notified him of the substance of the VCAA, including the type of evidence necessary to establish entitlement to service connection on a direct and presumptive basis, and of the division of responsibility between the Veteran and VA for obtaining that evidence. Consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), VA essentially satisfied the notification requirements of the VCAA by way of these letters by: (1) informing the Veteran about the information and evidence not of record that was necessary to substantiate his claims; (2) informing the Veteran about the information and evidence VA would seek to provide; (3) and informing the Veteran about the information and evidence he was expected to provide. Second, VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claims. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012). The information and evidence associated with the claims file consist of his service treatment records (STRs), VA medical treatment records, private post-service medical treatment records, Social Security Administration (SSA) records, VA examination reports, and statements from the Veteran and his representative. There is no indication that there is any additional relevant evidence to be obtained by either VA or the Veteran. It is specifically noted that the Veteran was informed in 2009 and in 2013 as to the unavailability of post service VA records from medical facilities in Shreveport, Louisiana, and Temple, Texas, respectively. The Board therefore finds that the duty to assist requirements of 38 C.F.R. § 3.159(c) have been satisfied with respect to obtaining post service VA medical records. The Veteran was afforded VA examinations in 2009 and 2013 regarding the correct diagnoses of and/or the etiology of bilateral knee conditions. In toto, these examination reports are deemed to be thorough in nature and adequate for the purposes of deciding these claims. The reports reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate physical examinations, and rendered appropriate diagnoses and opinions consistent with the evidence of record. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); and Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). Service Connection in General Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). However, continuous service for 90 days or more during a period of war, or peacetime service after December 31, 1946, and post service development of a presumptive disease such as DJD/arthritis to a degree of 10 percent or more within one year from the date of termination of such service, establishes a rebuttable presumption that the disease was incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113, (West 1991 & Supp. 2012); 38 C.F.R. §§ 3.303(d) (2012). This rule does not mean that any manifestations in service will permit service connection. To show 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 as distinguished from merely isolated findings or a diagnosis including the word "chronic". When the disease entity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). The United States Court of Appeals for Veterans Claims (Court) has held that, in order to prevail on the issue of service connection, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v West, 12 Vet. App. 341, 346 (1999). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. Additionally, when aggravation of a veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, the veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). 38 C.F.R. § 3.310 (2012). To establish service connection for tinnitus, the Veteran is not obliged to show that his tinnitus was present during active military service. However, if there is insufficient evidence to establish that a claimed chronic disability was present during service, the evidence must establish a nexus between his current disability and his inservice exposure to loud noise. Godfrey v. Derwinski, 2 Vet. App. 352 (1992). For purposes of 38 U.S.C.A. §§ 1110, 1131, and 1137, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002 & Supp. 2012). Service connection may be granted for congenital diseases, but not congenital defects. Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009) (discussing VAOPGCPREC 82-90); Monroe v. Brown, 4 Vet. App. 513, 515 (1993). When no pre-existing medical condition is noted upon entry into service, a veteran is presumed to have been sound upon entry. 38 U.S.C.A. § 1111 (West 2002 & Supp. 2012); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The presumption of soundness applies if a veteran's congenital disease is not noted at entry. See Quirin, 22 Vet. App. at 396-97, Monroe, 4 Vet. App. at 515. The burden then falls on the Government to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service. Wagner, 370 F.3d at 1096; Bagby, 1 Vet. App. at 227. Accordingly, [o]nce the presumption of soundness applies, the burden of proof remains with the Secretary on both the preexistence and the aggravation prong; it never shifts back to the claimant. In particular, even when there is clear and unmistakable evidence of preexistence, the claimant need not produce any evidence of aggravation in order to prevail under the aggravation prong of the presumption of soundness . . . the burden is not on the claimant to show that his disability increased in severity; rather, it is on VA to establish by clear and unmistakable evidence that it did not or that any increase was due to the natural progress of the disease. Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). This burden must be met by "affirmative evidence" demonstrating that there was no aggravation. See id. The burden is not met by finding "that the record contains insufficient evidence of aggravation." See id. "Both the plain language and legislative history of section 1111 make clear that the presumption of soundness can only be rebutted by clear and unmistakable evidence both that a condition existed prior to service and that it was not aggravated by service." Patrick v. Shinseki, 668 F.3d 1325, 1329 (Fed. Cir. 2011). A claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOGCPREC 3-2003 (July 16, 2003); see generally Cotant v. Principi, 17 Vet. App. 116, 124 (2003). The term "clear and unmistakable" means obvious or manifest. Cotant, supra. The word "unmistakable" means that an item cannot be misinterpreted and misunderstood, i.e., it is undebatable. Vanerson v. West, 12 Vet. App. 254, 258 (1999) (citing Webster's New World Dictionary 1461 (3rd Coll. ed. 1988); cf. Crippen v. Brown, 9 Vet. App. 412, 418 (1996) (stating that "clear and unmistakable error" means an error that is undebatable); Russell v. Principi, 3 Vet. App. 310 (1992) (en banc) ("The words 'clear and unmistakable error' are self-defining. They are errors that are undebatable, so that it can be said that reasonable minds could only conclude that the original decision was fatally flawed."). The Court has stated that the standard of proof for rebutting the presumption of soundness is not merely evidence that is cogent and compelling, i.e., a sufficient showing, but evidence that is clear and unmistakable, i.e., undebatable .... [and] the question is not whether the Secretary has sustained a burden of producing evidence, but whether the evidence as a whole, clearly and unmistakably demonstrates that the injury or disease existed prior to service. Cotant, supra, citing Vanerson, supra. If a disability is found to have preexisted service, then service connection may be predicated only upon a finding of aggravation during service. Paulson v. Brown, 7 Vet. App. 466, 468 (1995). A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153 (West 2002 & Supp. 2012); 38 C.F.R. § 3.306(a) (2012). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that a corollary to the Secretary's definition of "disability" in 38 C.F.R. § 4.1 is that an increase in disability must consist of worsening of the enduring disability and not merely a temporary flare-up of symptoms associated with the condition causing the disability. Davis v. Principi, 276 F.3d 1341, 1344 (Fed. Cir. 2002). The Federal Circuit stated: "[e]vidence of a temporary flare-up, without more, does not satisfy the level of proof required of a . . . veteran to establish an increase in disability." Davis, 276 F.3d at 1345; see Jensen v. Brown, 19 F.3d 1413, 1416 (Fed. Cir. 1994) (The Federal Circuit held that 38 U.S.C.A. § 1153 requires some increase in the severity of the pre-existing condition causally related to military service). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153 (West 2002 & Supp. 2012); 38 C.F.R. § 3.306(b) (2012). The Federal Circuit has rejected the view that competent medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Under 38 U.S.C.A. § 1154(a) (West 2002 & Supp. 2012), lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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. Davidson v. Shinseki, 581 F.3d. 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Tinnitus The STRs are negative for report of ringing in the ears during service. They do show, however, bilateral high frequency hearing loss upon more than one audiological exam (but not at time of separation). Post service VA audiological examinations in 2009 and 2012 also showed such loss. In the Board's April 2013 decision, it was noted that given the fact that current bilateral hearing loss disability was demonstrated in 2012 and also during service (although not at separation), adequate explanation had not been provided as why the inservice results should be ignored in favor of the separation results. With reasonable doubt resolved in the Veteran's favor, service connection for bilateral hearing loss was granted upon Board decision in April 2013. It is noted that the Veteran also reported ringing in the ears (tinnitus) at the time of these post service audiometric evaluations. The Board remanded the claim for service connection for tinnitus in the April 2013 decision for opinion addressing its etiology. In July 2013, a VA examiner reviewed the record and concluded that the tinnitus was less likely than not caused by or a result of military noise exposure. For rationale, she pointed out that the Veteran did not report tinnitus until 4-5 years ago. This was long after military service and tinnitus due to noise exposure has an onset immediate to the noise exposure. Moreover, his tinnitus began long after his hearing loss and was less likely than not caused or aggravated by such. Analysis With regard to the claim for tinnitus, the Board notes first that the Veteran's own statements are competent evidence to show that he has tinnitus since it is a subjective experience of ringing in the ears. Charles v. Principi, 16 Vet. App. 370, 374 (2002) (finding veteran competent to testify to symptomatology capable of lay observation); Layno, supra. The Board does acknowledge that the record includes a negative medical opinion in the case as to whether tinnitus was related to active service as summarized above. However, the Board has concluded that service connection is warranted for tinnitus as secondary to service-connected bilateral hearing loss. Concerning this, the Board notes that "an associated hearing loss is usually present" with tinnitus. The Merck Manual, Sec. 7, Ch. 82, Approach to the Patient with Ear Problems. Conversely, tinnitus may occur as a symptom of nearly all ear disorders including sensorineural or noise-induced hearing loss. Id. Finally, the Board notes that "high frequency tinnitus usually accompanies [noise- induced] hearing loss." The Merck Manual, Section 7, Ch. 85, Inner Ear. It is noted that the Veteran did not report hearing loss or tinnitus problems until many years after service. Still, the Board resolved reasonable doubt in this favor to find that his bilateral hearing loss was incurred during service. There is a current medical diagnosis of tinnitus. In light of the finding of a likely relationship between hearing loss and active service, the Veteran's competent credible testimony, a negative nexus opinion, and a current diagnosis, the Board concludes that the evidence is in equipoise with respect to whether the Veteran's current tinnitus is causally related to his service-connected bilateral hearing loss. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board will grant service connection for tinnitus. Left Knee and Right Knee The STRs are negative for report of, treatment for, or diagnosis of a right knee disorder. This includes a December 1979 separation exam report. As relevant, however, the STRs show that the Veteran gave a history of a trick or locked knee at time of service entrance. While no chronic left knee disorder was noted, there was fluid of that extremity noted. Shortly thereafter, in June 1977, effusion of the left knee was reported. At that time, it was noted that the Veteran had undergone a left meniscectomy prior to service. Subsequently, he was seen for left knee problems, primarily effusion, on numerous occasions during service. His inservice left knee problems were precipitated by physical activity. It was also noted that he had had left knee problems since he was 15 years old. He was placed on profile in 1978 due to his left knee problems. His left knee history was noted at time of separation exam in December 1979. When the Veteran filed a claim for service connection for knee disorders in September 2008, he alleged that he underwent additional left knee surgery at a VA facility in 1981. VA memorandum is also of record reflecting the unavailability of records from 1981. Post service private, SSA, and VA records dated from 1994 through 2013 are of record. Private records from 1994 show that the Veteran was seen for left knee pain after stepping in a hole. In July 1995, he was seen for right knee pain which was precipitated by injury when playing ball. Exam showed soft tissue damage, and the right knee was wrapped in a bandage. Arthritis in the left knee was noted by X-ray in August 1995. He was seen again with left knee complaints in October 1996 and intermittently through 2000 (as reflected in Texas Department of Criminal Justice Institutional Division) records. The Board notes that on more than one occasion, the Veteran gave a history of injuring his left knee in 1972 and again in 1981. VA examination in June 2009 noted bilateral DJD in the knees. The examiner opined that the Veteran's preexisting left knee condition was not aggravated during service, but no rationale for the opinion was provided. Thus, additional opinion was obtained in September 2013. After review of the claims folder, the examiner opined that the Veteran's left knee condition clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond its natural progression by an inservice event or illness. It was further noted that there was clear evidence that the left knee condition existed prior to service with fluid on the knee since the age of 15 and pre-service meniscectomy surgery in 1972. The examiner noted that inservice reports reflect that the Veteran was seen on numerous occasions for left knee effusion; but there was no indication that this was increased over the number that occurred prior to service or that the left knee condition was aggravated by service. She added that there was documentation of left knee strain in 1978/1979 when he was seen by a medical examiner. No chronic left knee condition was noted. Upon separation exam in December 1979, there was no mention of left knee problems or aggravation of such. She also noted that the Veteran had said that he had had additional left knee surgery shortly after service in 1981, but she saw no report of such, although she did see where he reported this as medical history on at least one occasion. Other than this report, the first mention of chronic left knee pain after service was in 1994 after he injured his left knee. She pointed out that he was also seen for left knee problems in 1995. Thus, she opined that there was no medical evidence of chronic left knee pain that was continuous after he left military service. The fact that the Veteran was playing ball in 1995 indicates that he was not suffering from a significant left knee condition. The examiner concluded by noting that the claims file reflected that the Veteran had a left knee disorder that preexisted service, and the medical evidence did not support that such was aggravated therein. Analysis Left Knee The Board has considered the evidence discussed above and finds that the presumption of soundness attaches to the Veteran, as a chronic left knee abnormality was not noted upon active duty enlistment examination in April 1977. However, shortly thereafter, detailed statements by the Veteran as to his pre-service history of left knee problems since the age of 15 with left knee surgery in 1972 were provided. These statements were presented contemporaneously with his inservice treatment for left knee complaints. His statements are deemed to be credible in the context of the time in which they were presented and, when viewed with the opinion of the service physician who examined the Veteran during active duty, establish that the Veteran's left knee disability - diagnosed at the time as acute strain - preexisted his entry into active service in 1977, thereby constituting clear and unmistakable clinical evidence which satisfies the first prong of the two prong test for rebutting the presumption of his physical soundness regarding his left knee at the time of his entry into military service. The opinion of the September 2013 VA examiner further demonstrates, by clear and unmistakable evidence, that the Veteran's preexisting left knee disorder did not undergo a permanent worsening beyond its normal clinical progression during active military service, and was not otherwise permanently worsened beyond its normal clinical progression as a result of any physical activity associated with his period of active military service. Thus, the second prong of the test to rebut the presumption of soundness is met and the presumption is rebutted. The Veteran's left knee disability both preexisted service and was not aggravated therein. The clinical evidence further indicates that the Veteran's post service left knee condition noted in the 1990s was precipitated by injury. His left knee arthritis was first noted after this injury (in 1995) and, as reported above, is unrelated to his inservice problems. Moreover, it is unfortunate that post service VA records have been deemed unavailable. While alleged post service left knee surgery in 1981 was reported on at least one occasion (e.g., when the Veteran filed for service connection in 2008), review of the available and more contemporaneous records simply reflects that the Veteran on occasion gave a history of left knee injury at that time. Moreover, it is noted that this injury with subsequent surgery was more than one year after military service. Without more, the Veteran's allegations as to post service left knee injury over a year after service do not provide credible or probative evidence suggesting that his preexisting left knee condition was aggravated during service, particularly when there was an intercurring injury. In considering the available medical evidence, the Board finds that the VA examiner's 2013 opinion is probative to show that the claimant's preexisting left knee condition was not aggravated during service. It is noted that she reviewed the claims file in providing her opinions. The probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). Accordingly, the Board has accorded great evidentiary weight to the VA physician who reviewed the record and concluded that the Veteran's preexisting left knee condition was not aggravated during service. Right Knee As to the Veteran's claim for a right knee disorder of service origin, it is noted that there was no complaint of, treatment for, or diagnosis of, a right knee condition until many years after service separation. Moreover, his initial right knee problems in 1995 were precipitated by injury. In the ensuing years, DJD in the right knee was noted. This also was many, many years after service separation. There is no medical opinion of record suggesting that the Veteran's DJD in the right knee is of service origin, and it was clearly not shown until many years after service separation. Moreover, his right knee complaints were precipitated by a post service sports injury. Final Considerations The Board acknowledges that lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. As such, the Veteran is competent to report symptoms such as knee problems, to include pain and impairment. However, he is not competent (meaning medically trained) to provide a complex medical diagnosis, such as diagnosing and opining as to etiology of orthopedic disability of the knees. Layno, Jandreau, supra. As such, his statements are insufficient to establish that he has bilateral knee disorders of service origin. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 3.102 (2009); Gilbert, supra. Therefore, the Board is unable to identify a reasonable basis for granting the Veteran's claims, on either a direct, aggravation or presumptive basis. ORDER Entitlement to service connection for tinnitus is granted. Entitlement to service connection for a left knee disorder is denied. Entitlement to service connection for a right knee disorder is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs