Citation Nr: 1338447 Decision Date: 11/22/13 Archive Date: 12/06/13 DOCKET NO. 13-18 702 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for a bilateral ankle disorder. 2. Entitlement to service connection for a bilateral knee disorder. REPRESENTATION Appellant represented by: Michael R. Viterna, Esq. ATTORNEY FOR THE BOARD G.R. Waddington, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1975 to March 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan, which denied service connection for a bilateral ankle disorder and a bilateral knee disorder. The Virtual VA paperless claims processing system does not contain any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. The Veteran does not have a diagnosis of a current bilateral ankle disorder. 2. The Veteran has a bilateral knee disorder that is not related to service. CONCLUSIONS OF LAW 1. The criteria for a grant of service connection for a bilateral ankle disorder have not been met. 38 U.S.C.A. §§ 1101, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 2. The criteria for a grant of service connection for a bilateral knee disorder have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board will discuss the relevant law, which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code (as noted by citations to "38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations (as noted by citations to "38 C.F.R.") and the precedential rulings of the United States Court of Appeals for the Federal Circuit (Federal Circuit) (as noted by citations to "Fed. Cir.") and the United States Court of Appeals for Veterans Claims (Court) (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d) (West 2002); see also 38 C.F.R. § 19.7 (2013) (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002), sets forth VA's duties to notify and assist claimants in substantiating claims for VA benefits. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In order to satisfy its duty to notify the claimant under the VCAA, the VA must inform the claimant of any information and 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. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). For service connection claims, proper notice of what is necessary to substantiate the claim requires that the claimant be informed of the following five elements: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006); Quartuccio, 16 Vet. App. at 187. All notice under the VCAA should generally be provided prior to an initial decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, a delay in timing of the notice is "cured," and therefore harmless, when a fully compliant VCAA notification letter [notice is] followed by readjudication of the claim (such as through issuing a Statement of the Case or Supplemental Statement of the Case) after the claimant has had an opportunity to submit additional evidence. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). Prior to the initial rating decision in this matter, an April 2009 letter notified the Veteran of all five elements of service connection and informed him of his and VA's respective responsibilities for obtaining relevant records and other evidence in support of his claims. Thus, the duty to notify is satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Dingess/Hartman, 19 Vet. App. at 484; Quartuccio, 16 Vet. App. at 187. VA's duty to assist under the VCAA includes helping the claimant to obtain service treatment records and other pertinent records. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The Veteran's service treatment records and VA medical records are in the claims file. Private medical records identified by the Veteran have also been associated with the file and he has not identified any other outstanding records or evidence. The duty to obtain relevant records is satisfied. See 38 C.F.R. § 3.159(c). The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran's June 2013 substantive appeal (VA Form 9) states that the February 2010 VA examiner's opinion is inadequate and requests a second VA examination. Similarly, his January 2013 statement states that the February 2010 VA examiner's opinion is inadequate and requests a second VA examination to address "the issue of aggravation as well as any increase in severity due to the natural progress of" the Veteran's knee disorder. Contrary to the Veteran's statements, the February 2010 VA examination report and opinion are adequate to decide his service connection claim for bilateral ankle and knee disorders. An appropriate VA examination was performed in February 2010. The examination report establishes that the VA examiner reviewed the claims file and the Veteran's self-reported medical history and examined the Veteran. The report also provides an explanation for the examiner's stated opinion, which enables the Board to make an informed decision. See Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion" even when the rationale does not explicitly "lay out the examiner's journey from the facts to a conclusion") (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)); see also D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). In addition, there are no apparent inconsistencies or ambiguities in the examination report. See Sickels, 643 F.3d at 1365-66; Rizzo, 580 F.3d at 1290-1291. Thus, the February 2010 VA examination report is adequate to decide the Veteran's claims for service connection. Moreover, the February 2010 VA examination report clearly addresses whether a relationship exists between the Veteran's disorders and his military service. Specifically, the report concludes that the Veteran's bilateral ankle and knee disorders are not due to military service. Even if the examination report did not adequately address whether the Veteran's disorders are related to service, the fact that the Veteran failed to report for a second VA examination scheduled in October 2012 without good cause requires the Board to decide his claim for direct service connection based on the evidence of record. 38 C.F.R. § 3.655 (a) & (b) (2013). Examples of good cause include, but are not limited to, "the illness or hospitalization of the claimant, death of an immediate family member, etc." Id. Accordingly, VA's duty to provide a VA examination is satisfied. See 38 C.F.R. §§ 3.159(c)(4); 3.326(a); McLendon, 20 Vet. App. at 83; Barr, 21 Vet. App. at 312. In summary, VA has satisfied its duties to notify and assist under the VCAA. The Veteran has had ample opportunity to participate in the development of his claim. See Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011) (citing Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding that any error depriving a claimant of "a meaningful opportunity to participate effectively in the processing of his or her claim . . . must be considered prejudicial")). As shown above, any defect in the notice or assistance provided did not affect the outcome of this claim or compromise the "essential fairness of the adjudication." See Mayfield v. Nicholson, 19 Vet. App. 103, 116 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, any error in the notice or assistance provided was harmless, and no prejudice exists. See Shinseki v. Sanders 556 U.S. 396, 407, 410 (2009) (holding that the "rule of prejudicial error" requires a case-by-case determination as to whether the error in question was harmless); see also 38 U.S.C.A. § 7261(b)(2) (West 2002) (providing that the Court must take due account of the rule of prejudicial error). The Board may proceed with appellate review. II. Analysis The Board has thoroughly reviewed the record, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Although the Board must review the entire record, it need not discuss each piece of evidence. See id. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The standard of proof to be applied in decisions on claims for veterans' benefits is the benefit-of-the-doubt rule set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must weigh against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board must assess the credibility and weight of all evidence, including both lay and medical evidence, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). This evaluation generally involves a three-step inquiry. First, the Board must determine whether the evidence is competent. See, e.g. Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Second, the Board must determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). Third, the Board must assess the probative value and weight of the evidence in light of the entire record. Gonzales, 218 F.3d at 1380-81. With regard to the competency of the evidence, lay statements submitted by or on behalf of a claimant can be competent with respect to both the diagnosis and the etiology or cause of a disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Thus, the Board may not "categorically" require medical evidence or disregard lay evidence without first assessing its competence. See id. (holding that it was error in a cause-of-death claim to find "categorically" that a medical opinion was required to prove a nexus between the Veteran's service-connected mental disorder and his drowning death, and likewise to reject categorically the claimant's testimony on this issue as not competent merely because she was a lay person); see also Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011) (holding that the Board erred in categorically rejecting lay evidence without analyzing and weighing it). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. See 38 C.F.R. § 3.159(a)(2); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). Lay evidence is competent if it is provided by a person who has first-hand knowledge of facts or circumstances, or conveys matters that can be observed and described by a lay person. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that appellant was competent to testify as to factual matters of which he had first-hand knowledge, such as experiencing pain in his right hip and thigh in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy). In this regard, lay evidence may be competent and sufficient to establish a diagnosis of a condition in the following circumstances: (1) when the condition is simple, such as a broken leg, as opposed to when the condition is more complex, such as a form of cancer; (2) when the layperson is reporting a contemporaneous medical diagnosis, or; (3) when lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372, 1377 & n4 (Fed. Cir. 2007). However, lay testimony is not competent with respect to determinations that are "medical in nature" or require medical knowledge due to their complexity. Barr, 21 Vet. App. at 309; see also Jandreau, 492 F. 3d at 1376-77 (observing that a lay person is not competent to identify more complex conditions such as a form of cancer). For example, the Court held that a claimant was not competent to determine whether he had rheumatic fever, which was a medically complex condition. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Board must discount the probative value of lay evidence if it finds such evidence not to be competent in light of the above guidelines. See King v. Shinseki, 700 F.3d, 1339, 1345 (Fed. Cir. 2012) (noting that lay evidence must "demonstrate some competence") (citing 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 3.307(b)) (internal quotation marks omitted)); see also Layno, 6 Vet. App. at 469 (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to that fact, and that incompetent testimony must be excluded from consideration). Competent medical evidence, as distinguished from lay evidence, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1); see also Layno, 6 Vet. App. at 469. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. 38 C.F.R. § 3.159(a)(1). It also includes statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. Id. The competency of evidence differs from the weight assigned to the evidence, which varies according to its credibility, probative value, and relationship to other items of evidence. See Layno, 6 Vet. App. at 469 (observing that the credibility and weight of testimony are factual determinations that must be distinguished from the initial assessment of its competency); accord Rucker v. Brown, 10 Vet. App. 67, 74 1997); see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probity of evidence in the light of its own inherent characteristics in its relationship to other items of evidence"); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (stating that "although interest may affect the credibility of testimony, it does not affect competency to testify."); Washington, 19 Vet. App. at 368 (noting that the witness's credibility affects the weight to be given to his testimony). The Veteran claims entitlement to service connection for a bilateral ankle disorder and a bilateral knee disorder. In his June 2013 substantive appeal (VA Form 9), the Veteran stated that he sustained a right-knee injury and experienced chronic pain in his right knee and lower leg when he was in service. In the same appeal, he stated that he has a current diagnosis of arthritis in both knees. For the reasons stated below, the Board finds that the Veteran's bilateral ankle and knee disorders are not related to service. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also 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). To establish service connection for a bilateral ankle or knee disorder, there must be competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). For the chronic diseases listed in 38 C.F.R. § 3.309(a), the evidentiary requirements for establishing entitlement to service connection benefits are more relaxed. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012) (holding that "[t]he clear purpose of [subsection 3.303(b)] is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases," and only applies to the chronic diseases set forth in § 3.309(a)). Specifically, § 3.303(b) provides that when a chronic disease is established during active service, subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless they are clearly attributable to causes unrelated to service ("intercurrent causes"). If the evidence is not sufficient to show that the disease was chronic at the time of service, then the claim may be established with evidence of a continuity of symptoms after service, which is a distinct and lesser evidentiary burden than the nexus element of the three-part test under Shedden. Walker, 708 F.3d at 1338-39 (observing that a claim for a chronic disease "benefits from presumptive service connection . . . or service connection via continuity of symptomatology"); C.F.R. § 3.303(b). Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during a] presumptive period." Walker, 708 F.3d at 1338-39. Because the Veteran has been diagnosed as having arthritis in both knees, and arthritis is defined as chronic diseases in section 3.309(a), the provisions of subsection 3.303(b) for chronic diseases apply, and a claim for a bilateral knee disorder may be established with evidence of chronicity in service or a continuity of symptomatology after service. See Walker, 708 F.3d at 1338-1339. In addition, where a claimant served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, service connection for arthritis, as a chronic disease, may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307; 3.309(a). This presumption may only be rebutted by affirmative evidence to the contrary. 38 C.F.R. § 3.307(d). With regard to the Veteran's service connection claim for a bilateral ankle disorder, the probative evidence does not establish a current diagnosis as is required by the first Shedden element. Shedden, 381 F.3d at 1166-67. The February 2010 VA examiner observed that "there is no record of ankle problems in the claims folder" or any "objective evidence" of such problems as of the date of the examination. He noted that the Veteran did not use ankle braces and that the power against resistance in his ankles was strong. He also noted that the Veteran exhibited normal range of motion in his ankles, no tenderness, deformity, or swelling on examination, and that x-rays of both his ankles were normal. Based on these findings, the examiner concluded that the Veteran had normal bilateral ankles without any evidence of weakness. Thus-although the Veteran's service treatment records show that he sprained his left ankle in August 1976 and was assessed with shin splints and low right-leg pain in May 1984-the probative evidence of record shows that the Veteran does not have a current bilateral ankle disorder. The existence of a current disability is the cornerstone of a claim for VA disability compensation; consequently, failure to establish a current disability results in the denial of a claim. 38 U.S.C.A. §§ 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328 (1997). Specifically, a claimant must have a disability in order to be considered for service connection. In Brammer v. Derwinski, 3 Vet. App. 223 (1992), the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. See also Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). Because the probative evidence fails to establish a current diagnosis for an ankle disorder, the Veteran's claim does not satisfy the first criterion for service connection and his claim must be denied. Shedden, 381 F.3d at 1166-67. With regard to the Veteran's service connection claim for a bilateral knee disorder, the evidence documents a current bilateral knee disability. A June 2004 MRI of the Veteran's right knee revealed degenerative joint disease involving the lateral femorotibial joint. In June 2007, additional diagnostic tests revealed "mild tricompartmental spurring" in the Veteran's right knee and in February 2009 radiology tests showed "[m]ild degenerative changes in the knees, more pronounced on the left." The February 2010 VA examiner noted that x-rays showed mild degenerative arthritis bilaterally and diagnosed the Veteran as having arthritis in both knees. Thus, the first Shedden element is satisfied for service connection for a bilateral knee disorder. The second Shedden element is satisfied with regard to the Veteran's right-knee disorder only. The Veteran's service treatment records show that in June 1978 he injured his right knee in a jeep accident and that he was treated for bruising, swelling, and a small abrasion to the right knee. The Veteran's service treatment records also show that he was treated for right knee and shin pain between May 1984 and February 1985. Thus, the evidence of record establishes that the Veteran injured his right knee in service. In contrast, the second Shedden element is not satisfied with regard to the Veteran's left-knee disorder. During his February 2010 VA examination, the Veteran reported that he experienced left as well as right knee pain while he was on active duty in Germany. However, his service treatment records do not document an in-service injury or disease or an in-service treatment for a left-knee disorder. The silence in the service treatment records regarding a left knee injury or symptoms weighs against the credibility of the Veteran's allegation of left-knee pain in active service. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (holding that silence in the service treatment records can constitute "contradictory" evidence weighing against the credibility of a claimant's testimony if the service treatment records are complete "in relevant part," and there is competent evidence that the claimed "injury, disease, or related symptoms would ordinarily have been recorded had they occurred"); Curry v. Brown, 7 Vet. App. 59 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant). Thus, the absence of any complaints of left-knee pain in service is persuasive evidence that the Veteran did not experience such pain during active duty and outweighs his present recollection to the contrary. The fact that the service treatment records document complaints of right -knee and -leg pain, but do not include reports of left knee pain further weighs against the credibility of the Veteran's February 2010 statement that he experienced left knee pain in service. The Board finds it implausible that the Veteran would report having right knee pain but not left knee pain while he was in service. AZ v. Shinseki, 731 F.3d 1303, 1311 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present); Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (citing FED. R. EVID. 803(7) for the proposition that "the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded"). Accordingly, the Veteran's contemporaneous service records are more probative than statements made approximately 20 years after separation from service and for purposes of VA compensation. Although the Veteran's right-knee disorder satisfies the first and second Shedden elements, the probative evidence does not satisfy the third Shedden element, which requires evidence of a nexus, or relationship, between the Veteran's current right-knee disorder and his service. See Shedden, 381 F.3d at 1166-67; Walker, 708 F.3d at 1338-1339. The Veteran's service treatment records do not show a relationship between his current right-knee disorder and his in-service injury. In May 1984-almost six years after he injured his right knee in a motor vehicle accident in June 1978-a medical consultation found that the Veteran had pain in his lower right leg, tenderness in the inside portion of his right shin, and that he walked with some discomfort, but had a normal range of motion in his right knee. Moreover, x-rays taken at the time were negative for bony abnormalities and the Veteran was assessed as having shin splints rather than a knee disorder. In August 1984, he reported having pain along the inner tibial shaft of his right leg and was against assessed with shin splints. Similarly, in September 1984 he reported right shin and knee pain and was assessed with shin splints. In December 1984, he was found to have medial right-knee tenderness, but no bony tenderness. In February 1985, the Veteran was treated for right knee pain and was exempted from training exercises for a week. The Veteran waived his right to a separation examination. Thus, the Veteran's service treatment records-that include x-rays that are negative for arthritis-do not indicate that his current bilateral knee disorder is related to his in-service injury or to his military service generally. The Veteran's post-service medical treatment records establish that his current bilateral knee disorder first manifested in June 2004 when he was hospitalized for right knee pain. Specifically, the Veteran reported a two-day history of increasing right-knee pain and swelling. He also reported that the redness and soreness in his right knee occurred at the end of a workday and that his work as a painter involved resting on his right knee "quite a bit" and putting pressure on the joint. As has previously been mentioned, a June 2004 MRI scan of the right leg revealed degenerative joint disease involving the lateral femorotibial joint. In addition, x-rays taken during his hospital stay showed mild degenerative changes in his right knee, including "minimal spur formations," but no fracture, dislocation, or periosteal reaction. The evidence does not otherwise suggest that his knee disorder began before June 2004-almost two decades after the Veteran separated from service in March 1985-or is otherwise related to his in-service injury. In February 2009, a private physician opined that the Veteran's service in the armed forces contributed to the development of his osteoarthritis of the knees. The physician based his opinion on a review of the Veteran's military personnel records and his treatment of the Veteran's arthritis, but did not provide a specific rationale for his opinion. In February 2012, the same private physician reiterated his earlier opinion. He stated that the Veteran's "service in the armed forces contributed to his development of his osteoarthritis of the knees." In February 2010, a VA examiner examined the Veteran and opined that "it is not as likely as not that" the Veteran's bilateral knee disorder is "due to his military service." The examiner noted that the Veteran injured his knee in a motor vehicle accident while he was serving in Korea and that he reportedly had bilateral knee pain after he was transferred to Germany. The examiner also noted that the Veteran braces his right, but not his left knee, that his right knee occasionally "pops out," and that his right knee pain is worsening despite taking pain medication. Moreover, x-rays revealed mild degenerative arthritis in both of the Veteran's knees. The VA examiner's physical examination of the Veteran revealed mild varus deformity in his left and right knees, no effusion or swelling in the knee joints, normal patellar position, no crepitation, and a range of motion of 0 to 135 degrees without any pain. Based on the above findings, the examiner concluded that the Veteran's "[m]ild degenerative changes of the knee joints are consistent with his age." The VA examiner's opinion is highly probative evidence that weighs against the Veteran's claim for service connection for a right-knee disorder. The examination was rendered by a medical expert who reviewed the claims file, considered the Veteran's self-reported medical history, and conducted a physical examination of the Veteran. In addition, the VA examiner's opinion is supported by a thorough explanation based on the facts of the case and the examiner's medical expertise. Specifically, the examination report states that the Veteran's arthritis is consistent with his age, rather than with his in-service injury or right-lower-leg pain. Thus, the report provides a clear rationale for finding against a relationship between the Veteran's current bilateral knee disorder and his in-service activities. In contrast, the private physician's opinion that the Veteran's military service contributed to his current arthritis is supported by a minimal rationale for his opinion. The physician stated that he has treated the Veteran for several years for arthritis and reviewed the Veteran's military record. However, he failed to explain how the Veteran's current arthritis is related to his military service. Thus, the private medical opinion has little probative value and is outweighed by the VA examiner's opinion, which is supported by a clear rationale. Similarly, the February 2010 VA examiner's opinion has more probative value than the Veteran's contention that his bilateral knee disorder (and ankle disorder) is related to his military service. Whether the Veteran's current arthritis in both knees was caused or aggravated by his military service is a determination that is medically complex and therefore cannot be made based on lay observation alone. See Jandreau, 492 F. 3d at 1376-77, n.4; see also Barr, 21 Vet. App. at 309. Instead, such a determination must be made by a medical professional with appropriate expertise. See id. Because the Veteran, as a lay person, has not been shown to have the appropriate medical training and experience, his assertion that his bilateral knee and ankle disorders are related to active service is not competent evidence and, therefore, is outweighed by the VA examiner's opinion, which was rendered by a medical professional. See Layno, 6 Vet. App. at 470-71. The fact that almost 20 years elapsed between service separation, in March 1985, and the earliest mention of a bilateral knee disorder, in June 2004, further weighs against a relationship to service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that, in assessing whether a claimed disorder was incurred in active service, a proper consideration for the trier of fact is the amount of time that has elapsed since military service). Moreover, the Veteran reported having a bilateral knee disorder only after he put pressure on his right knee as part of his occupation as a painter. Thus, the probative evidence of record weighs against a relationship between the Veteran's right-knee disorder and his military service. Based on the above analysis, the medical nexus element is not satisfied and service connection must be denied under 38 C.F.R. 3.303(a). See Shedden, 381 F.3d at 1166-67. Further, because the Veteran's arthritis did not manifest in service or for almost two decades after separation, service connection for a bilateral knee disorder as a chronic disease is not warranted under 38 C.F.R. § 3.303(b). Similarly, service connection is not warranted on a presumptive basis under 38 C.F.R. § 3.307 because the Veteran's arthritis did not manifest to a compensable degree within one year of service separation. The evidence of record does not establish the existence of arthritis in service or a continuity of symptoms after service. As previously mentioned, the Veteran's service treatment records do not show that he was diagnosed as having arthritis in service. Although he was treated for a right-knee injury in 1978, reported lower leg pain in May 1984, and complained of chronic right leg and knee pain in August 1984 and February 1985, the Veteran's service treatment records do not document the manifestation of symptoms sufficient to identity right-knee arthritis or left-knee problems in service. Specifically, x-rays performed in service were negative for bony abnormalities, an in-service medical consultation found no bony tenderness in the Veteran's right knee, and the Veteran's symptoms were associated with shin splints, not arthritis. The report of chronic right-lower-leg pain in service is not sufficient to establish that the Veteran had a chronic disease, namely arthritis, in service. 38 C.F.R. § 3.303(b). Thus, the Veteran's service treatment records provide affirmative evidence that the Veteran did not manifest arthritis in service. In addition, the first evidence of arthritis of the knees is from June 2004 when an MRI revealed degenerative joint disease in the Veteran's right knee joint. Thus, the probative evidence weighs against the Veteran's service connection claim for arthritis as a chronic disease under the provisions of 38 C.F.R. § 3.303(b). Similarly, the evidence of record does not show that the Veteran's arthritis manifested itself to a degree of 10 percent or more within a year from his separation from service in March 1985. 38 C.F.R. § 3.307. The Veteran's arthritis was first documented in June 2004-almost twenty years after he separated from service-when an MRI of the right knee revealed degenerative joint disease involving the lateral femorotibial joint. The fact that the Veteran's right-knee arthritis was first documented in June 2004 is consistent with the private medical opinion from February 2009, which states that the Veteran had been treated for arthritis for several years and with the VA examiner's opinion that the Veteran's mild degenerative changes of the knee joints were consistent with aging. Accordingly, the evidence weighs against the Veteran's service connection claim for arthritis on a presumptive basis. The preponderance of the evidence is against the Veteran's claims. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for a bilateral ankle disorder and a bilateral knee disorder is denied. See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. ORDER Entitlement to service connection for a bilateral ankle disorder is denied. Entitlement to service connection for a bilateral knee disorder is denied. ____________________________________________ Kelli A. Kordich Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs