Citation Nr: 1338620 Decision Date: 11/22/13 Archive Date: 12/06/13 DOCKET NO. 04-41 700 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a lumbar spine disability, to include as secondary to a right knee disability. 3. Entitlement to service connection for an acquired psychiatric disability, to include as secondary to a right knee disability and/or a lumbar spine disability. WITNESS AT HEARING ON APPEAL Appellant (the Veteran) ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from June 1973 to June 1975. This appeal comes before the Board of Veterans' Appeals (Board) from a March 2004 rating decision of the RO in St. Petersburg, Florida. In March 2007, the Veteran presented testimony at a Board hearing, which was chaired by the undersigned Veterans Law Judge sitting at the RO. A transcript of the hearing is associated with the claims file. In a decision dated in January 2011, the Board denied the issues listed on the title page above. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Veterans Court). In an Order dated in June 2011, pursuant to a Joint Motion for Remand (Joint Motion), the Veterans Court vacated the Board's January 2011 decision and remanded these issues back to the Board for development as stipulated in the Joint Motion. In October 2011, the Board remanded this appeal to the RO for additional evidentiary development. The appeal was again remanded, for corrective action, in August 2013. It has since been returned to the Board for further appellate action. The Board notes that the Veteran was represented by an attorney in this appeal at the time of the October 2011 Board remand; however, in January 2013, prior to the June 2013 certification of the appeal to the Board following remand, the Veteran's attorney withdrew from representation of the Veteran. The Veteran has not appointed a new attorney or accredited representative and is proceeding pro se. In reviewing this case the Board has not only reviewed the physical claims file, but also the electronic file on the "Virtual VA" system (including the Veterans Benefits Management System (VBMS)) to insure a total review of the evidence. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the appeal has been accomplished. 2. Osgood-Schlatter disease of the right knee was not noted at entry into service; however, Osgood-Schlatter disease of the right knee clearly and unmistakably preexisted service and clearly and unmistakably was not aggravated by service beyond the natural progress of the disorder. 3. No current right knee disorder is related to service. 4. No current disability of the lumbar spine is related to service or to any service-connected disability. 5. No current acquired psychiatric disability is related to service or to any service-connected disability. CONCLUSIONS OF LAW 1. A right knee disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1153, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306 (2013). 2. A lumbar spine disability was not incurred in service and is not proximately due to or a result of any service-connected disability; arthritis of the lumbar spine is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013). 3. An acquired psychiatric disability was not incurred in service and is not proximately due to or a result of any service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As noted in the introduction, the Board issued a decision in this case in January 2011 that was later vacated by the Veterans Court based on an agreement of the parties to the appeal that there were certain deficiencies in the Board's decision. The parties agreed that a September 2010 medical opinion relied upon by the Board was inadequate because the examiner did not follow the Board's instructions in a prior remand that, if it were found that the Veteran had no current residuals of Osgood-Schlatter disease since his discharge from active duty service in 1975, the examiner should attempt to reconcile a conflicting December 1993 VA examiner's opinion. The December 1993 VA examiner's opinion was in fact a diagnosis of Osgood-Schlatter disease secondary to trauma in adulthood. As found by the parties to the Joint Motion, the September 2010 examiner "did not attempt to reconcile his opinion as to the presence of Osgood Schlatter disease despite being directed to do so by the Board instead stating that he cannot reconcile that opinion with his own." See Joint Motion, page 5. The parties also stipulated that the September 2010 VA examiner did not provide an adequate rationale as to why the Osgood Schlatter disease that the examiner diagnosed as preexisting service was not aggravated by service. Thus, the matters remaining in dispute regarding this issue center on whether the Veteran's Osgood-Schlatter disease of the right knee predated service, and if so, whether it was aggravated by service. As set out in the January 2011 decision, a presumption of sound condition attaches when a veteran is 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. To rebut the presumption of soundness, the evidence must clearly and unmistakably show not only that the disorder at issue pre-existed entry into service, but clearly and unmistakably show that the disorder did not undergo aggravation in or as a result of service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). Here, the June 1973 enlistment examination does not include any notation of Osgood-Schlatter disease of the right knee or other knee disability. The Veteran's lower extremities were clinically evaluated as "normal." Therefore, the Veteran is presumed to have been in sound condition upon entry into service. During service, the Veteran was evaluated on several occasions for knee complaints and was diagnosed with Osgood-Schlatter disease during service. The Board acknowledges that the clear-and-unmistakable-evidence standard is an onerous one and requires in particular that the no-aggravation result be undebatable. Cotant v. Principi, 17 Vet. App. 116, 131 (2003). There are two components to aggravation. The first is a permanent worsening or increase in the level of disability. The second is a finding that the increase is beyond the natural progress of the disease. Established law requires that the Board must cite to medical authority or medical evidence in the record to support a conclusion that the Veteran's disability was not aggravated by service. Townsend v. Derwinski, 1 Vet. App. 408 (1991). After a review of all of the evidence, the Board finds that the evidence clearly and unmistakably establishes that Osgood-Schlatter disease of the right knee predated service. This is the first step necessary to rebut the presumption of soundness. VA regulations provide that, based on universally-recognized medical principles, certain disorders and the residuals of which are noted or discovered during service are deemed to have preexisted service. These disorders include such conditions as: scars; fibrosis of the lungs; atrophies following disease of the central or peripheral nervous system; absent, displaced or resected parts of organs; supernumerary parts; congenital malformations or; hemorrhoidal tags or tabs. With no evidence of the pertinent antecedent active disease or injury during service, the conclusion must be that they preexisted service. 38 C.F.R. § 3.303(c). Osgood-Schlatter disease is defined as an inflammation of bone and cartilage of the tuberosity of the tibia that occurs especially among adolescent males. See Buesing v. Brown, 14 Vet. App. 266 (1993) citing WEBSTER'S at 500-01. Osgood-Schlatter disease is also defined as an overuse injury with osteochondrosis of the tuberosity of the tibia. Osteochondrosis, in turn, is defined as a disease of the growth or ossification centers in children that begins as degeneration or necrosis and is followed by regeneration or recalcification. Trentman v. Shinseki, 2013 WL 2151771, No. 12-414 (May 17, 2013) citing Dorland's Illustrated Medical Dictionary 540, 1345 (32d ed. 2012). Thus, by definition, Osgood-Schlatter disease is a disease that arises before adulthood. This is consistent with pre-service origin. Moreover, with the exception of the December 1993 diagnosis, which the Board notes is entirely unexplained, the medical opinion evidence in this case uniformly finds that Osgood-Schlatter disease is inherently a condition that arises prior to adulthood, and is not a condition that is capable of adult onset. A VA orthopedic surgeon provided an expert medical opinion in April 2013 with a September 2013 addendum. First, he offered a definition for Osgood-Schlatter disease as a traction apophysitis condition that develops during adolescence as the tibial tubercle experiences patellar tendon traction during ossification. He noted that, in up to 10 percent of individuals, symptoms may persist into adulthood. The orthopedic surgeon concluded that Osgood Schlatter is a condition that begins in adolescence and not as an adult. According to the surgeon, "[t]his is a medical fact and is not debatable." The Board emphasizes the accepted meaning of clear and unmistakable evidence as evidence that is "undebatable." See Vanerson v. West, 12 Vet. App. 254 (1999); Quirin v. Shinseki, 22 Vet. App. 390 (2009). Second, the orthopedic surgeon reviewed imaging reports for the Veteran's right knee and found that these reports were consistent with a history of Osgood Schlatter disease. He noted that symptoms of Osgood-Schlatter disease may wax and wane and could certainly have been missed on a military entrance exam. The September 2010 VA examination findings are consistent with and supportive of the findings of the April 2013 examiner. The September 2010 examiner noted that the Veteran had bumps consistent with Osgood-Schlatter disease. According to the examiner, August 2006 right knee radiographs showed fragmentation of the tibial tuberosity often seen as residual radiographic findings in patients with juvenile Osgood-Schlatter disease. He found that the Veteran's radiographs were consistent with Osgood-Schlatter disease preceding the Veteran's entry into the military, which was highly likely to be pre-existing since that condition presented during adolescence prior to reaching skeletal maturity. The only medical evidence that arguably contradicts the September 2010, April 2013, and September 2013 findings comes from the brief (1-page) December 1993 VA examination report. That report noted the Veteran's history of an in-service fall on the right knee, noted the current complaints of pain and inability to kneel, noted an articular circumference in the right anterior tibial tubercle, and concluded with a diagnosis of "Osgood-Schlatter disease secondary to trauma in the adulthood." There is no discussion of any of the factors deemed significant by later examiners, there is no discussion of the pertinent literature regarding the pre-adult onset of Osgood-Schlatter disease, indeed, there is no discussion whatsoever. The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). In this case, the December 1993 examination is of limited scope, and there is no basis or reasoning provided for the opinion. Accordingly, the Board assigns the opinion little probative weight. To the extent the Veteran has expressed his belief that his Osgood-Schlatter disease of the right knee did not predate service, but began in service, the Board finds that this is not competent evidence. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, whether Osgood-Schlatter disease is a condition that develops during adolescence, or whether it is capable of adult onset, falls outside the realm of common knowledge of a lay person. Regarding the stipulation of the parties to the Joint Motion that the September 2010 opinion was deficient because the examiner did not "attempt to reconcile the conflicting December 1993 VA examiner's opinion," the Board must respectfully dispute the stipulation of the parties. This is not, as suggested by the parties, the equivalent of an inconclusive opinion, or a finding that an opinion cannot be rendered without resort to speculation. The September 2010 examiner directly disagreed with the opinion of the December 1993 opinion. The orthopedic surgeon who conducted the April 2013 examination and prepared the September 2013 addendum also directly disagreed with the conclusion of the December 1993 examiner. It is unclear what further reconciliation is possible beyond the expression of disagreement, or how these responses can be deemed the equivalent of an inconclusive opinion. The assertion of the parties appears to be that the Board intended that a medical professional should now be forced to explain an opinion of a different medical professional that was offered 20 years ago, without accompanying explanation or reasoning, and with which the current medical professional fundamentally disagrees. The Board finds that the expression of disagreement with the 1993 opinion offered by the September 2010 and April 2013 examiners, accompanied by their explanations for the disagreement, is all the reconciliation that is reasonable or necessary. Moreover, the Board stipulated in the July 2010 remand instructions that an "attempt" at reconciliation was requested. The September 2010 examiner's statement that "[t]his examiner cannot reconcile the conflicting December 1993 VA examiner's opinion" fully satisfies the Board's remand instruction that an "attempt" should be made. The examiner explicitly acknowledged the request and clearly and unequivocally informed the Board that a reconciliation was not possible. The Board respectfully disagrees with the parties to the Joint Motion and finds that its July 2010 remand instruction was adequately addressed by the September 2010 examiner, and that the April 2013 examiner, by expressing disagreement with the conclusion of the December 1993 examiner that Osgood-Schlatter disease may be capable of adult onset, and by providing detailed reasoning for this conclusion, also adequately addressed the Board's instruction. For these reasons, the Board finds that Osgood-Schlatter disease clearly and unmistakably existed prior to service, notwithstanding the normal clinical findings for the lower extremities on the service entrance examination. Having found that the evidence clearly and unmistakably establishes that Osgood-Schlatter disease of the right knee preexisted entry into service, the Board also finds that the evidence clearly and unmistakably establishes that Osgood-Schlatter disease of the right knee was not permanently worsened beyond the natural progress of the disease by service. This is the second step necessary to rebut the presumption of soundness. In addressing the evidence regarding aggravation, the Board will simultaneously address whether any current right knee disability other than Osgood-Schlatter disease is related to service. The Board acknowledges that the Veteran was treated in service for knee complaints and has current right knee diagnoses other than Osgood-Schlatter disease. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that no current disability of the right knee other than Osgood-Schlatter disease is related to service. Service treatment records reveal that the Veteran was first treated for right knee pain in November 1973, at which time there was point tenderness of the anterior tibial plateau at the insertion of the patellar tendon. There was no instability and drawer testing was negative. The possibility of Osgood-Schlatter disease was noted. An X-ray was taken of the Veteran's right knee which showed fragmentation of, and soft tissue prominence over, the tibial tubercle. A December 1973 orthopedic clinic note reveals the same complaint regarding "old O.S. disease." It is important to note that there was no injury reported in regard to the November 1973 treatment, and the only findings pertained to Osgood-Schlatter disease. In September 1974, the Veteran sought treatment after injuring his right knee while running three or four days prior to the visit. Following the physical examination, the only diagnoses were a contusion and nonunion of tibial tubercle fragment, which appears to be a reference to the Osgood-Schlatter findings previously reported. Thus, the Veteran was diagnosed with a contusion. A contusion is defined as a bruise or an injury of a part without a break in the skin (see Dorland's Illustrated Medical Dictionary 418 (31st ed. 2007)). In an October 1974 evaluation, it was again reported that the Veteran had a mild prominence of the tibial tubercle. An X-ray showed nonunion of the tibial tubercle. The Veteran had full range of motion and no instability or patellar crepitus was noted. In December 1974, it was again noted that the Veteran had probable old Osgood-Schlatter disease. At the time of the September 1975 service separation examination, in response to the question as to whether the Veteran had ever had or if he currently had a "trick" or locked knee, the Veteran responded "no." The Veteran's lower extremities were clinically evaluated as "normal." Thus, the service separation examination indicates that, to the extent of a right knee injury in 1974, there were no residuals at service separation. This is also probative evidence that there was no permanent worsening in the Osgood-Schlatter disease during service. The Veteran's Osgood-Schlatter disease of the right knee was repeatedly noted in the service records; however, the only other diagnosis is a contusion associated with an injury in 1974. The normal clinical findings at separation must be compared to the also-normal clinical findings at entry. The fact that there was found to be no disability at service separation, despite occasional complaints of knee pain during service is obvious and unmistakable evidence that there was no permanent worsening of the Osgood-Schlatter disease of the right knee during service. The Board acknowledges that the Veteran reported in a June 1982 claim that he was hospitalized in Fort Jackson in Korea for a knee injury. However, on the report of medical history at service separation, he answered "no" to the question have you ever been a patient in any type of hospitals? The Board finds the statement at service separation to be more reliable than his current recollection made in the course of a claim for benefits. The service treatment records directly contradict his 1982 assertion, which the Board finds to be inaccurate. After service, there is no record of complaint or treatment regarding the right knee for many years. Significant in terms of a relationship between the in-service injury and a current disability is the fact that the current claim was not the first claim for disability compensation filed by the Veteran since service separation. The Veteran filed claims in January 1978, April 1978, and August 1980; however, at those times, he noted only "nerves" and "nervous condition" as related to service. The Veteran did not mention any knee problems. Indeed, in April 1978, the Veteran underwent a VA examination, at which time an examination of the musculoskeletal system was conducted and revealed no abnormal findings. The first reference to knee complaints comes in June 1982, approximately 7 years after service separation. In June 1982, the Veteran filed his initial claim for service connection for a right knee disability. VA Medical Center outpatient treatment records, dated from June 1982 to November 1983, show that, in June 1982, the Veteran was treated for right knee pain. At that time, he gave a history of right knee trauma in 1973, with subsequent weakness of the right leg. The Board notes that the service records directly contradict the assertion that there was a "trauma" in 1973. The Veteran was treated for pain, but there was no injury reported. Examination of the extremities in June 1982 showed normal functioning knees with no limitation of motion. The impression was of history of internal derangement of the right knee. The records reflect that, in August 1982, the Veteran was again treated for right knee pain, reporting a history of a 1973 right knee injury. The diagnosis was osteoarthritis of the right knee, status post trauma 1973. While inaction for many years regarding filing a claim is not necessarily indicative of the absence of symptomatology, where, as here, a veteran takes action regarding other claims, it becomes reasonable to expect that the Veteran is presenting all issues for which he is experiencing symptoms that he believes are related to service. In other words, the Veteran demonstrated as early as 1978 that he understood the procedure for filing a claim for VA disability compensation, and he followed that procedure in instances where he believed himself entitled to those benefits. In such circumstances, it is reasonable to expect a complete reporting of symptoms. Thus, the Veteran's inaction regarding a claim for a right knee disorder, when viewed in the context of action regarding other claims, may reasonably be interpreted as indicative of the lack of symptomatology at that time. A lack of symptomatology for an extended period after service is probative evidence that there is no etiologic link between the in-service injury and post-service diagnoses and is probative evidence against an in-service aggravation of Osgood-Schlatter disease. In addition, the Board notes that, although there is a current diagnosis of arthritis of the right knee, such did not become manifest to any degree within a year of service separation, but first appeared in November 2003. Regarding the opinion evidence, the December 2009 VA examiner opined that the Veteran's current right knee arthritis was consistent with normal age-related degenerative changes. According to the examiner, Osgood-Schlatter disease would not likely result in degenerative changes in the articular surface of the knee joint. Thus, the Veteran's right knee arthritis did not appear to be an aggravation of the Osgood-Schlatter disease. The December 2009 VA examiner acknowledged the Veteran's account that he injured his right knee in service and subsequently developed chronic right knee pain. X-rays from August 2006 were noted as showing mild tricompartmental arthritis. The Board notes that the August 2006 X-rays were reported to show degenerative changes as well as a bony density adjacent to the tibial tubercle with new soft tissue swelling anterior to the tibial tubercle which may be due to Osgood-Schlatter disease. The December 2009 examiner diagnosed mild degenerative joint disease of the right knee and opined that it was less likely as not (less than 50/50 probability) that the Veteran's degenerative joint disease of the right knee was caused by or a result of his military service. The September 2010 VA examiner also found that the Veteran did not have any current residuals of Osgood-Schlatter disease. The examiner noted that the Veteran's radiographs were consistent with Osgood-Schlatter disease preceding the Veteran's entry into the military and was highly likely to be pre-existing since that condition presented during adolescence prior to reaching skeletal maturity. The examiner opined that the Veteran's Osgood-Schlatter disease was not aggravated during active military service. The September 2010 examiner interpreted August 2006 right knee radiographs showing fragmentation of the tibial tuberosity as not clinically significant or relevant in the Veteran's case. The examiner noted that there is an absence of measurable right thigh circumference atrophy compared to the left thigh circumference and one would reasonably expect right thigh atrophy in cases of clinically significant knee conditions/disorders. The absence of right thigh atrophy compared to the left thigh circumference supported a non-organic contribution to the Veteran's right knee pain report. The examiner further opined that the Veteran's current right knee condition was not caused by or a result of the reported right knee injury during active military service. The September 2010 examiner also stated that he was unable to identify evidence that would support a nexus between the Veteran's active military service and his current right knee condition. In regard to a rationale for his opinion, the examiner indicated that the Veteran's history of a fall and direct injury to the flexed knee in 1973 was consistent with a right knee contusion and did not cause an internal derangement of the Veteran's right knee. That was confirmed by the absence of right knee arthroscopic findings in April 2006 that would be deemed to be consistent with a clinically significant internal derangement. The September 2010 examiner also addressed the results of an October 2004 MRI, which was reported to show possible anterior cruciate ligament partial tear; patellar tendon partial tear or degeneration; lateral collateral ligament partial tear; lateral meniscus posterior horn partial tear; and chondromalacia patellae. These results were found to be non-concordant with the findings at the time of the 2006 right knee arthroscopy, as those MRI findings were not identified at the time of the April 2006 right knee arthroscopy. The reported right knee MRI findings in October 2004 lacked clinical correlation with the right knee arthroscopic findings in April 2006. The September 2010 VA examiner opined that it was coincidental that the direct injury to the Veteran's right knee in service involved the area of the Veteran's tibial tuberosity, which is the area affected by Osgood-Schlatter disease. His examination of the Veteran's right knee did not identify any tenderness to palpation of the tibial tuberosity or distal patellar ligament. Absence of those clinical findings supported his opinion that a residual of the Veteran's right knee Osgood-Schlatter disease was not the cause of the Veteran's current right knee condition. The April 2013 examiner also provided an opinion as to aggravation, finding that there was no aggravation in this case. He reasoned that, although physical activity could induce pain, if Osgood-Schlatter disease of the right knee had been aggravated beyond its natural course, he would expect to see excessive tibial tubercle fragmentation or separation. He noted that this is not the case in this Veteran (based on recent imaging). He also noted that this Veteran has current evidence of right knee internal derangement, which is in no way related to Osgood Schlatter disease. Thus, the opinion evidence, in particular the April 2013 and September 2010 opinions, establishes clearly and unmistakably that the clinical findings reflecting Osgood-Schlatter disease are essentially unchanged from those noted in service. The post-service knee disabilities (arthritis and internal derangement) are diagnostically distinct from Osgood-Schlatter disease and therefore cannot be deemed an aggravation of that disease. Moreover, the arthritis and internal derangement were not noted in service and are not consistent with the contusion sustained in 1974. The Board acknowledges that the Veteran has repeatedly asserted to healthcare providers and to VA that he has experienced ongoing symptoms since the injury in service. The Veteran has at times reported that he injured his knee in 1973. This is not supported by the service records, which show only complaints of pain. He has alternatively reported that his symptoms started after he fell in 1974. However, the Veteran complained of knee pain in 1973, prior to the 1974 injury. Thus, his symptoms clearly did not begin with the in-service injury, but predated the injury by at least a year. While the Veteran is competent to describe the onset of symptoms, his current assertion as to onset of symptoms corresponding to the 1974 injury is not accurate. Moreover, the Veteran has never accounted for the fact that he sought disability compensation for depression in 1978, but despite his recent assertion that he was experiencing right knee pain continuously since service, he did not mention any problem with his knee at that time. There are several medical opinions based on the Veteran's inaccurate account. A private medical statement from M.B., M.D., dated in June 2005, notes that the Veteran had right knee pathology which included osteoarthritis, bilateral chondromalacia, and the partial tears of several ligaments. Dr. B. opined that the condition of the Veteran's right knee pathology "can be greatly related" to a previous old trauma in 1974. In a statement from Dr. M.B., received in December 2008, Dr. B. stated that the Veteran had a history of a right knee trauma in approximately 1973, and that, since that time, he had experienced right knee pain. Dr. B. indicated that, at present, the Veteran was still symptomatic. He noted that the Veteran also had a history of a meniscus tear in the right knee with subsequent arthroscopy. Dr. B. opined that he could say that the Veteran hurt his right knee in 1973 while he was in the military, and with time, the right knee became worse. Again, the Board notes that the Veteran did not injure his right knee in 1973. He was treated for right knee pain in 1973, but there was no injury until 1974. This inaccuracy undermines the opinion of Dr. B., as it highlights the lack of information available to him as to the Veteran's condition in service. It is not apparent that Dr. B. is even aware of the diagnosis of Osgood-Schlatter disease of the right knee. Moreover, the opinion is inherently based on the Veteran's inaccurate account of continuous symptoms since the in-service injury. Finally, both statements of Dr. B. appear to be inconclusive. The use of terminology such as "can be" and "could say" expresses equivocation and uncertainty. Medical evidence which merely indicates that the particular disorder "may or may not" exist or "may or may not" be related to service, is too speculative in nature to establish the presence of said disorder or the relationship thereto. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). The medical opinion evidence which demonstrates an understanding of the pertinent facts and timeline in this case is, with the exception of the December 1993 report, decidedly against a permanent worsening in the Osgood-Schlatter disease of the right knee during service. As already discussed, the December 1993 report is not accorded significant probative weight because the examiner provided only a cursory evaluation and provided no discussion of his findings. Moreover, the opinion is inconsistent with generally accepted medical principles regarding the nature of Osgood-Schlatter disease, as cited by the September 2010 and April 2013 examiners, and is deemed to be factually inaccurate. Thus, the only medical opinion evidence regarding aggravation of Osgood-Schlatter disease of the right knee or causation of any other right knee disability by service that is based on an accurate factual premise and that is conclusively reported comes from the December 2009, September 2010, and April 2013 VA examiners. In sum, the evidence clearly and unmistakably demonstrates that the Veteran's Osgood-Schlatter disease of the right knee was not aggravated by service. It exists now, essentially unchanged, as it did in service. Moreover, the weight of the evidence demonstrates that no other disability of the right knee is related to service. Although the Veteran sustained a contusion to the right knee in 1974, this resolved without residuals by the time of service separation. Having found that clear and unmistakable evidence demonstrates a pre-existing condition of Osgood-Schlatter disease of the right knee which was not aggravated by service, the presumption of soundness is rebutted. The Veteran had Osgood-Schlatter disease of the right knee at entry into service, and the pre-existing condition was not aggravated by service. Accordingly, service connection for incurrence of Osgood-Schlatter disease of the right knee is not warranted and service connection for aggravation of Osgood-Schlatter disease of the right knee is not warranted. In addition, as there is no etiology between any current right knee disability other than Osgood-Schlatter disease of the right knee, service connection for a right knee disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Regarding the assertion that a psychiatric disability and a low back disability are secondarily related to a knee disability, as the Board has found that service connection for a right knee disability is not warranted, the claims of entitlement to service connection on a secondary basis must fail. Service treatment records reveal no treatment for back complaints or psychiatric complaints during service. At separation, the Veteran's spine was clinically normal and the Veteran was found to be psychiatrically normal. The Veteran does not contend that he was treated for back complaints in service. He has related his current back complaints to his right knee disability. He has also alternatively related his current psychiatric complaints to the right knee disability and directly to service. In April 2007 correspondence, he asserted that when he was in Korea he was treated 2 times for psychiatric problems. In relation to a 1978 claim, he alleged that he was treated for a nervous condition in April 1974 while in Korea. Also in April 2007, the Veteran's mother wrote that, since he left the army, he has not been the same person that he was before entering the army. His character and his personality are not the same. The Board finds that the current assertion of the Veteran, although competent evidence, is materially inaccurate. The Board notes not only the normal psychiatric findings on the separation examination, but the Veteran's own account of his medical history at service separation. He reported that he had no history of depression, excessive worry, or nervous trouble of any sort. Moreover, he answered in the negative (no) to the question, have you ever been treated for a mental condition? These reports directly conflict with his current assertion that he was treated for psychiatric problems in service. In weighing the conflicting statements provided by the Veteran, the point in time in which the statement was made is important because a recounting of an event which is closer to the time that event occurred is naturally less likely to be diluted by the shortcomings of human memory. Thus, the contemporaneousness of the statement of medical history at discharge is significant. Furthermore, because the Veteran was then seeking only medical evaluation, it seems likely that he would report events carefully and accurately. Statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care. In contrast, when the Veteran thereafter presented his account, he was seeking VA benefits rather than medical treatment. The Board is of course cognizant of possible self interest which any veteran has in promoting a claim for monetary benefits. The Board may properly consider the personal interest a claimant has in his or her own case, but the Board is not free to ignore his assertion as to any matter upon which he is competent to offer an opinion. See Pond v. West, 12 Vet. App. 341, 345 (1999); and see Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). There is no question that the Veteran is competent to relate events as he remembers them. Thus, his competency is not at issue with regard to recounting the events of service. Rather, it is the credibility of the Veteran's recent account which the Board finds is lacking. Simply put, the report of medical history at separation from service is more convincing than the Veteran's later statements made in support of a claim for monetary benefits. While the Veteran's mother is also competent to report that her son was not the same after service, the assertion that the Veteran was not the same is not probative evidence that he had incurred a psychiatric disability. Establishing the onset of a psychiatric disability is not capable of lay observation. To the extent that she is asserting that a psychiatric disability began in service, the medical examination findings at service separation are assigned greater probative weight than the lay speculation of the Veteran's mother. The Veteran separated from service in 1975. The first claim for compensation for any disability appears in January 1978, at which time, the Veteran listed "nerves." He noted that, since discharge, he had suffered from nerves. In an August 1980 claim, the Veteran again listed "nervous condition." He reported that this condition is connected to the military service because he was treated on "many occasions for several conditions." It is unclear what was intended by the quoted assertions; however, to the extent he was contending that he was treated for psychiatric problems on "many" occasions, this not only conflicts with the report of medical history, but also appears to be inconsistent with his prior accounts, which referred to 2 treatments and 1 treatment, respectively. An April 1978 psychiatric evaluation reveals the Veteran's account that he had used LSD, marijuana, and heroin, and that he hallucinated after he tried to get rid of drugs. The examiner found it difficult to specify the onset of his problems, but he claimed that "for a long time" he felt very restless, would get angry easily, and preferred to be alone. The examiner noted that the earliest hospitalization was in January 1978. Again, this directly contradicts the Veteran's assertion that he was treated in service. Regarding the back, a medical certificate dated in June 1995 reveals that the Veteran fell 7 months prior and was complaining of low back pain in the right paralumbar region. The diagnosis was a muscle spasm. In a December 1999 medical certificate, the Veteran reported left sided low back pain and left lower extremity pain for the past 2 weeks. He reported onset of pain when lifting heavy boxes approximately 1 month prior. He denied any prior back problems or history of back pain. X-rays revealed degenerative joint disease of the lumbar spine. A medical certificate dated in July 2001 reveals complaint of low back pain during waking hours with 3 years of evolution. In August 2001, the Veteran was found to have degenerative disc disease and degenerative joint disease lumbar spine. A July 2001 X-ray revealed minimal to moderate degenerative lumbar spondylosis, and discogenic disease at the L5-S1 level with reduction of intervertebral space. Thus, the Veteran's back complaints have onset many years after service and appear to correspond to post-service injuries. There is no medical opinion that purports to relate a current back disability or a psychiatric disability to service or to any service-connected disability. The Veteran's opinion is based primarily on his belief that the disabilities are related to his knee disability, which is not a service-connected disability. To the extent he has related a psychiatric disability to service, this is based on an inaccurate history of having been treated in service for psychiatric complaints. The Board has found this to be contradicted by his own contemporaneous accounts. As there is no etiologic relationship between a current back disability or psychiatric disability and service or any service-connected disability, the Board finds that service connection for the claimed back disability and psychiatric disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The Veteran has not asserted any deficiency in the notice provided by the RO for any of these claims. The evidence obtained includes the Veteran's service treatment records, post-service VA and private treatment records, and records from the SSA. The evidence also includes the Veteran's written assertions and hearing testimony. When conducting a hearing, a VA hearing officer, to include a Veterans Law Judge, must suggest that a claimant submit evidence on any issue material to substantiating the claim when the record is missing any evidence on that issue or when the testimony at the hearing raises an issue for which there is no evidence in the record. See Bryant v. Shinseki, 23 Vet. App. 488 (2010); 38 C.F.R. § 3.103 (2013). The hearing officer also must suggest the submission of evidence when testimony during the hearing indicates that it exists (or could be reduced to writing) but is not of record. Here, during the hearing, the Veteran's symptomatology and history were discussed in detail, and testimony concerning his level of impairment and his theories of etiology was elicited. Such actions supplement the VCAA and comply with 38 C.F.R. § 3.103. In addition, the Veteran was afforded several VA examinations to address the etiology of his claimed right knee disability and whether his Osgood-Schlatter disease of the right knee preexisted service and was aggravated by service. As discussed by the Board in more detail above, these examinations were adequate because each was performed by a medical professional based on a review of claims file, solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. The resulting opinions were accompanied by rationales that were consistent with the record. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). As noted above, this appeal involves a remand by the Board for additional evidentiary development. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). While substantial compliance is required, strict compliance is not. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In this case, the RO substantially complied with the Board's remand instructions by scheduling a VA orthopedic examination for the purpose of determining the nature, severity, and etiology of any Osgood-Schlatter disease of the right knee. The examiner provided an opinion on whether the Veteran currently has any residuals of Osgood-Schlatter disease of the right knee, and attempted, but was unable, to reconcile his opinion with the conflicting December 1993 VA examiner's opinion. As discussed in detail above, the April 2013 VA examiner expressed disagreement with the December 1993 opinion and explained the basis for this disagreement. The Board finds that this fully satisfies the request at reconciliation. The examiner was also asked to provide an opinion as to whether it is at least as likely as not (50 percent or more likelihood) that the Veteran's pre-existing Osgood-Schlatter disease of the right knee was aggravated during service beyond its natural progression. The April 2013 found that there was no aggravation, but that the current right knee disabilities are unrelated to Osgood-Schlatter disease. In correspondence received in July 2012, the Veteran's former attorney asserted that the October 2011 opinion request misstated the appropriate legal standard with respect to rebutting the presumption of soundness by asking the examiner, "is it at least as likely as not (50 percent or more likelihood) that the Veteran's pre-existing Osgood-Schlatter's disease of the right knee was aggravated during service beyond its natural progression?" The Board acknowledges that, while the standard used in the Board's instruction was deferential to the Veteran, it was not as deferential as the applicable standard of proof requires. To rebut the presumption of soundness, there must be clear and unmistakable evidence both that Osgood-Schlatter disease predated service and that it was not aggravated by service. The Board acknowledges that there was at least a potential for misinterpretation of the legal standard in the Board's wording. However, in this case, there is no prejudice to the claim resulting from this potential. The April 2013 opinion is that Osgood-Schlatter disease by definition must have predated service, and that, the current right knee disabilities are fundamentally distinct from the Osgood-Schlatter disease. There appears no possibility that the opinion was in any way qualified because of a misunderstanding of the standard of proof. The Board acknowledges that the Veteran has not been afforded a VA medical examination with respect the claimed back and psychiatric claims. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Veterans Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet the standard of subsection (B), as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, the Veteran has not asserted that the claimed back disability is related to service. He has asserted that it is related to an altered gait resulting from the right knee disability, which is not service-connected. The only evidence that the Veteran's claimed psychiatric disability is related to his military service are his own conclusory generalized lay statements, some of which are materially inaccurate, and which are unsupported by even speculative medical evidence. Accordingly, the Board finds that referral for a VA medical examination is not warranted. ORDER Service connection for a right knee disability is denied. Service connection for a lumbar spine disability is denied. Service connection for an acquired psychiatric disability is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs