Citation Nr: 1338782 Decision Date: 11/25/13 Archive Date: 12/06/13 DOCKET NO. 07-39 577 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder other than an anxiety disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for degenerative joint disease, left knee. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Harrigan Smith, Counsel INTRODUCTION The Veteran had active service from June 1969 to July 1974, and states he had reserve service thereafter. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) issued in January, June and October 2006 by the Huntington, West Virginia, Regional Office (RO) and by the Columbia, South Carolina, RO. During the pendency of this claim, jurisdiction of the claims files has been transferred to the Louisville, Kentucky RO. In October 2011, the Board reopened the Veteran's claim for entitlement to service connection for an acquired psychiatric disorder other than an anxiety disorder, to include posttraumatic stress disorder (PTSD), and remanded the remaining issues for additional development. The issue of entitlement to service connection for an acquired psychiatric disorder other than an anxiety disorder, to include PTSD, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT Left knee degenerative joint disease did not manifest during service or within one year of discharge, and is not shown to be causally or etiologically related to service. CONCLUSION OF LAW The criteria for service connection for left knee degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) defined VA's duty to assist a Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Under the VCAA, 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. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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 of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a pre-adjudication letter dated in July 2005, the RO notified the Veteran of the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). This letter also informed him of the types of evidence that would be considered to substantiate his claim and the information and evidence needed to sustain a claim for service connection. In addition, the Veteran was provided with a letter in December 2006 that met the notice requirements set out in Dingess. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Any timing error with regard to this notice has been resolved by the readjudication of the claim in subsequent supplemental statements of the case, the most recent issued in December 2012. Neither the Veteran nor his representative has alleged that notice has been less than adequate. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (holding that a party alleging defective notice has the burden of showing how the defective notice was harmful). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). Post-service medical records have been associated with the claims file. 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). The Board remanded this case in October 2011 in order to obtain the Veteran's reserve records, to obtain all pertinent VA medical records since April 2008, and to ask the Veteran to identify any non-VA clinical evidence related to the claims on appeal, and to provide the Veteran with a VA examination in order to determine whether he had a left knee disorder that is related to active duty. The Veteran's reserve records and current VA medical records have been obtained and associated with the record. The Veteran was provided with a letter in July 2012 that asked him to identify any additional private physician that had treated him for his left knee disability; however, the Veteran did not respond to that letter. Finally, the Veteran underwent a VA examination in February 2012 to determine whether his left knee disorder is related to service. The Board finds that this VA examination is adequate because, as shown below, it was based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because the reports describe the disability in detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. Service Connection - Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. A current disability must be present for a valid service connection claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (complaints of pain alone do not meet the current disability threshold); Evans v. West, 12 Vet. App. 22, 31-32 (1998). More recently, the Court has held that the current disability requirement is satisfied when a claimant has a disability at the time of filing the claim or during the pendency of that claim, even if the disability has since resolved. McLain v. Nicholson, 21 Vet. App. 319 (2007). If certain chronic diseases such as arthritis become manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of such disability during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The Court has recently held that, for chronic diseases listed under 38 C.F.R. § 3.309(a), service connection can be established by showing that the disability has been chronic since active duty. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (noting that the continuity of symptomatology provisions apply only to listed chronic conditions). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay 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." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ('[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence'). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Background and analysis The Veteran contends that his left knee problems began during active duty as a result of a motor vehicle accident in service in 1969. The Veteran's service treatment records reflect that he was in a motor vehicle accident in November 1969. He reported pain in his lower back and numbness in his legs. In March 1972, he reported left knee pain, but that he could not recall any trauma to his left knee. There are no other service treatment records that show complaints of or treatment for a left knee disorder. His February 1973 Report of Medical Examination reflects normal lower extremities, with no mention of a left knee disorder. His contemporaneous Report of Medical History shows that the Veteran indicated he did not have a trick or locked knee, lameness or a bone, joint or other deformity. The Veteran did check a box indicating that he had arthritis, rheumatism, or bursitis. The examiner who performed his separation examination indicated that this response referred to spasms in his lower back. His September 1974 separation examination was also normal with regard to his lower extremities. The Veteran the examiner noted that he had back spasms as a result of his in-service motor vehicle accident, but made no mention that he had injured his left knee in this incident. The Veteran did not report any problems with his left knee at separation, and, in fact, on his September 1974 separation Report of Medical History, he indicated that he did not have a "trick or locked" knee, lameness, arthritis, rheumatism or bursitis, or any bone, joint or other deformity. Reserve records do not reflect any left knee problems. A February 1978 Report of Medical Examination reflected a normal left knee, and Reports of Medical History in February 1978 and May 1982 show that the Veteran indicated that he did not have a trick or locked knee, bone, joint or other deformity, arthritis, rheumatism, or bursitis. VA medical records showing treatment for various medical issues from September 1976 to December 1993 do not reflect any treatment for a left knee disability. A July 2005 letter from the Veteran's private physician, R.E.G., M.D., reflects that he had been treating the Veteran for problems with left knee pain for many years. He indicated that the Veteran felt that his left knee disorder was due to a motor vehicle accident in which he was involved in 1969. The private physician noted that the Veteran did experience a knee injury in the accident, and that it was possible that this accident was the initial cause of his chronic knee pain. August 2006 VA medical record shows that the Veteran complained of left knee pain that had started the night before with no known cause, although he did report that he worked in construction. An August 2006 x-ray revealed mild degenerative narrowing involving the medial compartment. A December 2007 letter written by his daughter who was 27 years old shows that she reported observing the Veteran with knee problems as far as she could remember. She also reported that her father had told her that his left knee problems began with an in-service motor vehicle accident. A May 2008 VA examination shows that the Veteran reported that he was involved in a motor vehicle accident in July 1969, and that his left knee hit the door handle when his car was struck. The Veteran complained of progressive pain, swelling, stiffness, of his left knee since the time of the motor vehicle accident. A December 2007 X-ray revealed degenerative narrowing of the medial compartment, and a November 2007 left knee magnetic resonance imaging study (MRI) revealed mild to moderate degenerative joint disease in the medial compartment with a posterior meniscal tear. There was moderate effusion and chondromalacia patella. The examiner found that it was less likely as not that the Veteran's left knee disability was caused by or a result of his military service, in particular, the in-service motor vehicle accident and the notation of left knee pain in 1972. The examiner provided the rationale that the Veteran's current symptoms appeared to be most consistent with his meniscal tear, which most likely occurred when the Veteran had a twisting injury in September 2007. Although the Veteran complained of left knee pain, no records indicating the cause of the problem could be found and therefore the examiner could not tell what degree of degenerative changes were present in the past and what are recent given his acute injury. The examiner noted that the evaluation in-service did not demonstrate any symptoms to signify a significant injury at that time. Notes from the PCP showed that the Veteran's left knee pain was well-controlled with NSAIDS leading up to his twisting injury in 2007. Given the lack of specific symptoms resulting in acute injury, the examiner found that it was less likely as not caused by or the result of military service and the in-service motor vehicle accident. Private medical records showing treatment in February 2009 show that the Veteran had severe medial compartment and patellofemoral compartment osteoarthritic changes. A September 2009 private physician's medical records show that the Veteran reported a long history of left knee pain. An October 2009 letter from a fellow service member who indicated that he had known the Veteran for about 10 to 12 years, and that his mobility had decreased. He reported that the Veteran had mentioned that a motor vehicle accident when he injured his back and knee. A November 2009 letters from the Veteran's mother, wife and daughter shows her report that the Veteran has had left knee problems since 1969 when he was in a car wreck while on active duty. The Veteran had a left total knee replacement performed in October 2009. A VA opinion was obtained in February 2012. The examiner found that the Veteran's left knee disability was less likely than not related to military service. He reviewed the evidence of record, and provided the rationale that review of the evidence of record failed to reveal evidence of a significant left knee disorder in the service treatment records. The examiner noted that the single reference to the left knee symptoms in March 1972 was considerably after his 1969 motor vehicle accident, and specifically excluded trauma as the cause. Subsequent service treatment records did not include complaints of a left knee condition. The examiner opined that the Veteran's left knee pain was clearly related to his degenerative arthritis. Although a history of continuity of symptoms was provided, there was no medical evidence in the active or reserve service treatment records sufficient to provide a diagnosis of a condition likely to give rise to the Veteran's current condition. Contrarily, degenerative joint disease of the left knee is well known to develop in the absence of trauma, and is in general felt related to a genetic predisposition, age and body mass index. Therefore, the examiner found that a relationship of the Veteran's current left knee condition to service appears unlikely. The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan, supra. The evaluation of evidence generally involves a three step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Then, the Board must determine whether the evidence is credible. The Board must make an express credibility finding regarding lay evidence. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Finally, the Board must weigh the probative value of the proffered evidence in light of the entirety of the record. In assessing the evidence of record, the Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). The competence of evidence, the Court has held, is a legal concept, which is useful in determining whether testimony may be heard and considered by the trier of fact, while the credibility of such evidence is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker, 10 Vet. App. at 74. See also Layno, supra. The medical evidence of record clearly shows that the Veteran has a current left knee disability meeting one of the fundamental requirements of service connection. Brammer, supra. Thus, the issue in this case is whether the evidence of record, including medical and lay evidence, attributes his left knee disability to service. The Veteran reported that he began having left knee pain after a motor vehicle accident in service. The Board notes that he is competent to report symptoms that the lay witness observed and is within the realm of his or her personal knowledge; that is, those which are perceived through the use of the senses. Layno, supra. Knee pain falls into such a category. Therefore, the Veteran is competent to provide lay evidence with regard to his left knee pain. As noted above, however, the inquiry regarding his lay evidence does not stop here. The Board is required to make a determination with regard to the credibility of the lay evidence in the record which supports the Veteran's claim. In such an instance, the Veteran's credibility affects the weight to be given to his testimony, and it is the Board's responsibility to determine the appropriate weight. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When weighing lay evidence such as this, the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character. Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (citing State v. Asbury, 415 S.E.2d 891, 895 (W. Va. 1992)). Personal interest may also affect the credibility of the evidence. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). In this case, the Board finds that the Veteran's reports of left knee pain that began with the in-service motor vehicle accident and have continued to the present are not credible, for the following reasons. The Veteran's service treatment records reflect only one report of pain in the left knee pain, three years after his motor vehicle accident. However, this is the only report of left knee pain in the service treatment records. In fact, at the time of separation, the Veteran indicated that he did not have left knee discomfort or problems with this left knee. These lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value. The records were generated with a view towards ascertaining the appellant's then-state of physical fitness, they are akin to statements of diagnosis and treatment and are of increased probative value. Rucker v. Brown, 10 Vet. App. 67, 73 (1997). In addition, the Veteran has contradicted himself with regard to the onset of his left knee pain. At his examination in May 2008, the Veteran reported that his knee pain began in service after the motor vehicle accident; however, in August 2006, the Veteran reported that his knee pain began the night prior. In addition, as noted above, the Veteran reported that he did not have knee pain when he left service. For these reasons the Board concludes that the Veteran's statements with regard to the in-service onset of his back and the continuation of it from his discharge are not credible. The Board notes that VA medical records showing treatment over a 17 year period following service reflect that the Veteran was treated for various medical issues; however, at no time during this treatment period did the Veteran report any problems with his left knee. This tends to diminish the reliability of the Veteran's statements that he has had ongoing knee pain since his in-service motor vehicle accident. Id. Finally, the Veteran's statements with regard to the in-service onset of his back pain are not consistent with the medical evidence of record. While the Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, the Board may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan, 451 F.3d at 1336-37Id. at 1337. VA medical records showing treatment for other medical issues from 1976 to 1993 do not reflect any treatment for a left knee disorder. In other words, there is no medical evidence of a left knee disability for at least 20 years after his discharge from active duty. The lack of medical evidence, when considered in addition to the inconsistency of the Veteran's statements, weighs against a finding of credibility in his statements. Therefore, the Board finds that the probative weight of the medical and lay evidence of record is against a history of a left knee disability during service or any continuity of symptomatology after the Veteran's military service. 38 C.F.R. § 3.303(b). The Board notes that the Veteran also submitted lay statements from his family members and a fellow service member who support the Veteran's contentions that his left knee disability began in service. The Board emphasizes that personal interest may affect the credibility of the evidence. Cartright, supra. While the Veteran's family members may not have a direct personal interest in assisting the Veteran with obtaining VA benefits, they are, at the very least, not dis-interested parties. This weighs against the credibility of their statements. In addition, while sincere in their belief, the Board notes that these statements were made over 35 years after the Veteran's discharge from service. Considered in light of the Veteran's conflicting statements regarding the onset of his left knee pain, this passage of time weighs against the credibility of these lay statements. Finally, these statements are not supported by the medical evidence of record. This additionally tends to diminish the credibility of these statements, along with their probative value. Buchanan, supra. In terms of evidence providing an etiology between the Veteran's current left knee disorder and his time on active duty, there are conflicting medical opinions as to the etiology of the Veteran's current left knee disorder. The Board, therefore, must weigh the credibility and probative value of this evidence, and in so doing, may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). The Board must account for the evidence it finds persuasive or unpersuasive and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 29-40 (1994). The record includes a letter from the Veteran's private physician who opined that it was "possible" that the in-service motor vehicle accident was the initial cause of left knee pain. The Board finds that this opinion does not provide any probative value in this case, as the examiner did not provide any rationale for this opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ('[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.'). In addition, and the law provides that service connection may not be based on a resort to speculation or remote possibility. 38 C.F.R. § 3.102 (2013); Obert v. Brown, 5 Vet. App. 30, 33 (1993). A May 2008 VA examiner found that the Veteran's knee disability was not related to service; however, this examiner appeared to base this opinion on the fact that the Veteran's reported discomfort at his examination was related to a twisting injury to his knee sustained in 2007, without addressing the Veteran's earlier reports of pain. See Reonal v. Brown, 5 Vet.App. 4458, 460-61 (1993) (medical opinion based on an inaccurate factual premise has no probative value). As such, this opinion is not probative as to the etiology of the Veteran's left knee disability. The Board finds that the VA opinion provided in February 2012 provides the most probative evidence with regard to whether the Veteran's left knee disability is related to service. This examiner based his opinion on a complete and accurate review of the Veteran's history, and provided a thorough rationale for the opinion provided. As such, this opinion has the most probative value in determining whether the Veteran's left knee disability is related to service. As such, there is no competent medical evidence of a nexus between the Veteran's current left knee disability and his active duty. Boyer, supra. Arthritis is a disorder for which presumptive service connection is available. However, for the same reasons as set out about regarding service connection, there is no evidence in the claims file that the Veteran's arthritis in his left knee manifested to a compensable degree within one year of his discharge. Therefore, service connection on a presumptive basis is not warranted. 38 C.F.R. §§ 3.307, 3.309. With regard to the statements provided by the Veteran and his family and friend relating his current left knee disability to service, the Board observes that while lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, they are not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). In this case, the Board finds that the question regarding the potential relationship between his current left knee disability and any instance of his military service to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). Therefore, the Board finds that the contentions made by the Veteran and his family and friend, regarding the etiology of his left knee disorder, are outweighed by the competent and probative VA examiner's findings. As such, the Board finds that service connection for degenerative joint disease of the left knee is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the appellant's claim of entitlement to service connection for left knee degenerative joint disease. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107. ORDER Service connection for left knee degenerative joint disease is denied REMAND Once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). In its October 2011 remand, the Board instructed that the Veteran should be provided with a VA examination to obtain diagnoses for any current psychiatric disorder, then to determine whether there was clear and unmistakable evidence that a psychiatric disorder preexisted service and, if so, whether there was clear and unmistakable evidence that the disability was not aggravated during service. The examiner was also to provide an opinion as to whether a current psychiatric disorder was related to service. The Veteran was provided with a psychiatric examination in February 2012. The examiner diagnosed depressive disorder and alcohol abuse. She provided the opinion that the Veteran's psychiatric disorder clearly and unmistakable preexisted service and was clearly and unmistakable not aggravate during service. The examiner provided the rationale that, due to the lack of evidence it would be speculative to comment on whether the Veteran's may have suffered from undiagnosed psychiatric disorder prior to his military service. She also found that, since the Veteran did not seek psychiatric treatment while in the military, it was unlikely that his depression was related to military service. The Board finds that clarification is needed for this opinion. First, the opinion is internally inconsistent. The examiner initially found that there was clear and unmistakable evidence that the Veteran's psychiatric disability preexisted service, then she indicated that it would be speculation to comment as to that issue. In addition, the examiner based her opinion that the Veteran's psychiatric disorder was not related to service on the absence of treatment in his service treatment records; however, the examiner did not consider the Veteran's statements regarding his in-service onset of psychiatric symptoms. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the etiology of any diagnosed psychiatric disorder. All indicated tests and studies should be conducted. The claims folder, including this remand, must be sent to the examiner for review; consideration of such should be reflected in the completed examination report or in an addendum. The examiner should opine as to: a) whether there is clear and unmistakable evidence that any diagnosed psychiatric disorder preexisted service, and, if so, whether there is clear and unmistakable evidence that the preexisting psychiatric disorder was not aggravated by during service (clear and unmistakable evidence means evidence that cannot be misinterpreted and misunderstood, that is, the evidence is undebatable); b) if a psychiatric disorder did not preexist service, it is at least as likely as not (50 percent probability or more) that the Veteran's psychiatric disorder was caused by or is etiologically related to any incident of active duty. In providing this opinion, the examiner must address the Veteran's contentions of in-service harassment by his superior and, for purposes of this examination, consider these reports to be credible. The examiner must provide reasons for each opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner should provide a reason for doing so. 2. If any benefit on appeal remains denied, the AOJ should issue a supplemental statement of the case. Thereafter, the case should be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ J.A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs