Citation Nr: 1339965 Decision Date: 12/04/13 Archive Date: 12/18/13 DOCKET NO. 07-33 138 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a right hip disorder, to include as secondary to left knee disorder. 2. Entitlement to service connection for a left hip disorder (claimed as trochanter calcification of left femur), to include a secondary to left knee disorder. 3. Entitlement to service connection for a lumbar spine disorder, to include as secondary to left knee disorder. 4. Entitlement to service connection for a heart disorder, to include as secondary to left knee disorder. 5. Entitlement to service connection for left lower extremity sciatica and numbness (claimed as left leg nerve damage), to include as secondary to left knee disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant, and Dr. C.N.B. ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran had active service from December 1965 to December 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which denied the above-referenced claims. In July 2009, and February 2011, the Board remanded the claims for additional development. The Board subsequently obtained advisory medical opinions through the Veterans Health Administration (VHA). In April 2009, the Veteran and Dr. C.N.B. testified at a video conference hearing, held at the RO, over which the undersigned Veterans Law Judge presided. A transcript of that hearing has been associated with the claims file. FINDING OF FACT The evidence of record does not show that the Veteran has a right hip disorder, a left hip disorder, a lumbar spine disorder, a heart disorder (to include hypertension), or left lower extremity sciatica and numbness, that is related to active duty service, or that was caused or aggravated by a service-connected disability. CONCLUSION OF LAW A right hip disorder, a left hip disorder, a lumbar spine disorder, a heart disorder (to include hypertension), and left lower extremity sciatica and numbness, were not incurred in, or otherwise due to, the Veteran's active duty service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013); 38 C.F.R. § 3.310 (as in effect prior to October 10, 2006). REASONS AND BASES FOR FINDING AND CONCLUSION I. Service Connection The Veteran asserts that he has a right hip disorder, a left hip disorder, a lumbar spine disorder, a heart disorder (to include hypertension), and left lower extremity sciatica and numbness, that are related to active duty service, or that were caused or aggravated by a service-connected disability. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted on the basis of a post-service initial diagnosis of a disease, when "all of the evidence, including that pertinent to service, establishes that the disease was incurred during service." See 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be established for a current disability on the basis of a presumption under the law that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Arthritis and cardiovascular-renal disease (including hypertension and organic heart disease) can be service connected on such a basis; however, as will be explained in more detail below, the record is absent evidence of any of these conditions within a year following the Veteran's discharge from service. With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. Feb. 21, 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.303(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a); and that continuity of symptomatology only relates the specified chronic diseases). A grant of service connection under 38 C.F.R. § 3.303(b) does not require proof of the medical nexus. Id. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Additionally, when aggravation of a Veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). VA amended its regulation pertaining to secondary service connection, effective from October 10, 2006. See 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310). The new regulation appears to place additional evidentiary burdens on claimants seeking service connection based on aggravation; specifically, in terms of establishing a baseline level of disability for the non-service-connected condition prior to the aggravation. Because the new law appears more restrictive than the old, and because the appellant's claim was filed in January 2006 (for the left hip), and was pending when the new provisions were promulgated, the Board will consider this appeal under the law in effect prior to October 10, 2006. See, e.g., Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (new regulations cannot be applied to pending claims if they have impermissibly retroactive effects). With regard to all claims other than the left hip, service connection may be granted, on a secondary basis, for a disability, which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310 (2013). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). The Veteran's service treatment reports do not show any relevant complaints, treatment, findings, or diagnoses. The Veteran's separation examination report, dated in October 1968, shows that his heart, spine, and lower extremities, were clinically evaluated as normal; his blood pressure was 140/80. An associated chest X-ray was negative. An associated "report of medical history" shows that the Veteran indicated that he did not have a history of pain or pressure in his chest, palpitation or pounding heart, high or low blood pressure, arthritis or rheumatism, recurrent back trouble, neuritis, or paralysis. There is a notation of "good health." See also January 1966 OCS (officer candidate school) examination report (same). As for the post-service medical evidence, it consists of VA reports, dated between 1998 and 2013. The relevant evidence is summarized as follows: VA progress notes show that in March 2003, the Veteran was noted to have hyperlipidemia, and to have a family history of CAD (coronary artery disease), and CVA (cardiovascular accident). He denied having any musculoskeletal problems. In July 2003, the Veteran was noted to have a history of arthritis, and back pain, and to be using Coumadin. The report also notes atrial fibrillation of "new onset." In July 2004, he was noted to have a history of treatment for atrial fibrillation beginning in March 2004. In July 2006, he was noted to have a history of atrial fibrillation, arthritis, and to be taking medications that included Coumadin and hydorcholorthiazide. He also reported that he was taking medications due to arthralgia and muscle pain, but that he "had been doing quite nicely for the past 12 months." Reports, dated in April and October of 2008, and March and April of 2009, note that he did not have arthralgias or paresthesias, but that he had left knee pain and heel pain, and show that heart examinations were unremarkable. The March and April 2009 reports note complaints of burning feet, use of neurontin and warfarin, and assessments of peripheral neuropathy. As of August 2009, his "problem list" included peripheral nerve disease, arthralgia of the knee, and hyperlipidemia. Private treatment reports, dated between 1998 and 2010, show that in December 1998, the Veteran reported taking medication for control of his cholesterol, and that he was treated for complaints that included occasional soreness of the low back. There was no diagnosis. In March 2001, the Veteran was noted to have a family history of atherosclerotic heart disease, and cardiovascular accident. In May 2001, the Veteran was treated for complaints of a three-week history of low back pain. The diagnosis was scaroiliitis. An electrocardiogram (EKG) was normal. The impressions included essential hypertension, hyperlipidemia, and osteoarthritis. A June 2001 report shows treatment for an episode of "vague chest discomfort," with a normal echocardiogram, except for mild atrial regurgitation as well as slightly increased right-sided dimensions. A November 2001 report characterized the June 2001 testing as "completely negative." An August 2003 report notes a history of an MVA (motor vehicle accident) in June 2003, in which his car was struck in the rear by another car, he was pushed 35 feet by the collision, followed by pain in areas that included the left leg. An October 2003 report notes that an EKG was normal. A December 2003 report notes that the Veteran was hospitalized for atrial fibrillation, confirmed by EKG, and that he had no previous history of cardiac disease. The assessments included atrial fibrillation with a rapid ventricular response, chest discomfort of unclear etiology, and hyperlipidemia. Later that same month, the Veteran underwent procedures that included a left heart catheterization, left ventriculography, ascending aortography, and a right and left coronary arteriography. The impressions were normal left ventricular function, normal ascending aortography, and normal coronary arteriography. A December 2003 echocardiogram contains impressions that included left atrial enlargement, mild mitral regurgitation, trace to mild tricuspid regurgitation, and trace pulmonic insufficiency. See also April 2004 echocardiogram. A May 2004 report shows that the Veteran was instructed to lose weight. His assessments included atrial fibrillation, hypertension, mitral and tricuspid regurgitation, and hyperlipidemia. A June 2004 report shows that the Veteran was noted to have been thrown from a horse in May 2004, "with the onset of right low back pain." The impression was lumbar contusion without evidence of spinal cord nerve root compression with no radiographically-evident fracture. Another June 2004 report notes that X-rays showed multilevel degenerative changes with osteophyte formation at L1-L2, and no obvious compression fracture. An October 2004 report notes that the Veteran has atherosclerotic heart disease, hypertension, hyperlipidemia, and osteoarthritis, and that his hyperlipidemia and mild hypertension are "longstanding." A February 2005 report notes "overweight status," and that his gait was normal. Between May 2005 and 2006, the Veteran was treated for complaints of a ten-year history of left hip pain. X-rays were noted to show calcification "and a few flex of calcium about the greater trochanter," bilaterally. A May 2005 X-ray report for the lumbar spine contains a conclusion noting multi-level mild to moderate spondylosis, and mild anterior vertebral body height loss at L1, although there was no focal bone lesion noted. A May 2005 X-ray report for the hips notes "minimal symmetric hip DJD," and it contains a conclusion noting "no acute findings." A May 2005 bone scan contains an impression of "no signification abnormality." There are several subsequently-dated notations of left trochanteric bursitis, and tendonitis of the iliotibial band. A December 2005 report notes the recent presence of gout. See also June 2007 report (noting bilateral foot gout). In July 2006, the Veteran complained of symptoms that included "almost passing out," and left leg pain and numbness. The diagnosis was TIA (transient ischemic attack). A January 2008 report notes that the Veteran was obese. See also March 2009 report. An October 2008 report shows that the Veteran denied having had good symmetric movement bilaterally with no focal deficits, and that he denied having leg pain or swelling while walking. A December 2008 report notes bilateral knee arthritis, severe on the left and moderate on the right, and that the Veteran would soon require a total knee replacement. He was also noted to have bilateral greater trochanteric bursitis. Another December 2008 report notes a history of osteoarthritis of the hips. A January 2009 report notes that the Veteran underwent a total knee replacement, left, and that he had left trochanteric bursitis. A February 209 report notes DJD (degenerative joint disease) of the left hip. In February 2011, the Board remanded the claims, and directed that the Veteran be afforded examinations, and that etiological opinions be obtained. VA heart, and spine, examination reports, dated in May 2011, show that the examiner stated that the Veteran's claims file had been reviewed. The diagnoses were hypertension, atrial fibrillation, "mild tricuspid regurgitation - normal finding in adults," DJD of the lumbar spine, with no objective evidence of a sciatic disorder noted. With regard to the hips, the examiner stated that there was no objective evidence of a bilateral hip disorder. The examiner also stated that there was no objective evidence of a sciatic disorder on examination. The examiner concluded that it was less likely as not that the Veteran's lumbar spine disorder was caused by, or a result of, his military service. The examiner explained the following: the Veteran has degenerative changes in his lumbar spine which are commensurate with his age, and which are documented to have begun after a 2003 MVA, and after a fall off of a horse in 2004. The Veteran had normal exercise activity as of 2003, and a normal gait noted in 2005, which would indicate the Veteran's lumbar spine condition was not due to any inability to exercise, or abnormal gait. The Veteran's lumbar spine disorder is more likely due to the effects of aging coupled with the effects of the 2003 MVA and his fall off of a horse. The examiner cited to medical literature on the etiology of lumbar spine disorders which states that there are two categories of risk factors associated with back pain (extrinsic and intrinsic), and that degenerative arthritis of the spine typically affects individuals over the age of 60 (citation omitted). Associated X-rays for the hips contain an impression of "no abnormalities appreciated." An associated X-ray report for the lumbar spine notes displaced narrowing and spurring at L2-3 and facet arthropathy of L5-S1. With regard to hypertension, the examiner concluded that the Veteran's hypertension was not caused by, or a result of, military service, and that it was not due to any lack of exercise due to his service-connected knee condition. The examiner explained that he did not meet the criteria for hypertension during service, and that following separation from service, he was treated for essential hypertension as early as 2001, at which time he stated that he had no restrictions on his ability to exercise. With regard to atrial fibrillation, the examiner concluded that the Veteran's atrial fibrillation was not caused by, or a result of, military service. The examiner explained that the Veteran developed atrial fibrillation in December 2003, and that up until that time, he had a history of hypertension, and a normal capacity for exercise, in 2001. Therefore, his atrial fibrillation is not secondary to service, or to any inability to exercise, and it is most likely related to the effects of aging. The examiner cited to medical literature on the etiology of atrial fibrillation which states that the prevalence and incidence of atrial fibrillation increases with advancing age (citation omitted). In March 2013, the Board requested a VHA (Veterans Hospital Administration) opinion as to the Veteran's claims for lumbar spine and bilateral hip disabilities, after noting that the May 2011 VA examiner had not discussed the favorable opinions of Dr. C.N.B. (discussed infra). In April 2013, a VHA opinion was received from J.M.V.V., Neurosurgery Section Chief, Ann Arbor VA Health Care System. Dr. J.M.V.V. indicated that he had reviewed the documentation, and that the case is complex, with multiple variables, and in general, it is difficult to determine a direct connection between lumbar spine degenerative pathology with pain and a service-connected disorder of another weight-bearing joint such as the left knee without an in-person examination. Nevertheless, Dr. J.M.V.V. stated that he was able to find important information after a careful chart review. Dr. J.M.V.V. states the following: the Veteran's claim that his left knee condition is related to his lumbar spine condition conflicts with certain documentation in his chart, "which point to the contrary in my opinion." The Veteran's May 2004 treatment, following a fall off of a horse, indicates that the area involved in the accident/trauma appears to have been very extensive and painful to touch on exam, which reflects significant trauma to the tissues and muscles around the lumbar spine. In general, such trauma to the paraspinal tissues can cause long-term back pain which can be muscular and arthritic in nature, and which can certainly be an important cause of pain in this case, independent of his left knee disability. The Veteran was also taking Coumadin at the time of his injury, which can cause excessive bleeding even after minor trauma, muscle hematomas, scarring, and increase the chances of chronic pain from these injuries in the lower back. Reports dated in August 2003 mention that the Veteran was involved in a MVA where his car was struck in the rear by another car. Such trauma can create significant forces in the lumbar spine even when restrained with a seatbelt, and should be taken into consideration when evaluating causes of the Veteran's back pain. There is documentation of a lumbar spine fracture likely caused from the fall from a horse, although there was no CT (computerized tomography) scan to confirm this. The presence of a lumbar spine fracture, if accurate, can also be a cause of back pain, independent from pathology on another weight-bearing joint. Dr. B's October 2006 letter describes multi-level lumbar spine degenerative changes, vacuum disc phenomenon, and facet sclerosis. These findings are not corroborated, but these findings fall into the category of lumbar degenerative changes, which can develop in a patient with no knee pathology as well. Dr. V concludes: The above findings lead me to believe that any diagnosed lumbar spine disorder is not at least as likely as not related to his left knee disability. I do not think one can directly establish causation between his left knee pathology and his lumbar degenerative changes given the other variables such as trauma to the lumbar region, which can also cause long-term low back pain. In May 2013, the appellant was provided with a copy of the April 2013 VHA opinion, and he was informed that he had 60 days to review the opinion and send any additional evidence or argument. 38 C.F.R. § 20.903 (2013). In June 2013, the Veteran and his representative essentially argued that Dr. V's statement, to the effect that, in general, it is difficult to determine a direct connection between lumbar spine degenerative pathology with pain and a service-connected disorder of another weight-bearing joint such as the left knee without an in-person examination, showed that his opinion warranted reduced probative weight. It was further argued that his opinion warranted reduced probative weight as he was unable to review Dr. C.N.B's X-rays, as referenced in Dr. C.N.B's October 2006 report. In July 2013, the Board requested VHA opinions as to the Veteran's claims for lumbar spine and bilateral hip disabilities. In August 2013, a VHA opinion was received from D.R.A., M.D., an orthopedic surgeon, who indicated that he had reviewed the Veteran's medical records. With regard to the issue of whether the Veteran has a disability, such as bursitis, that may result in the complained of pain and observed tenderness of the left or right hip, Dr. D.R.A. stated: The Veteran does have a reported complaint of tenderness in his left hip, but this complaint was identified and recorded after his total knee arthroscopy. It is apparent he was walking stiffly and uncomfortably in his follow-up evaluation in the orthopedic surgeon's office. Therefore, the impairment of complaint of hip tenderness was the result of his recent surgery from his left total knee arthroplasty. This is predicted to be a temporary occurrence and is not a permanent disability and is not the result of his service-connected knee disorder. He has a past history of hip pain that was injected with good results. With regard to the issue of whether any hip disability is related to active duty service, Dr. D.R.A. stated: In response to [this question] the Veteran does not have a disability of the right or left hip and his complaints of tenderness in the left hip are not related to active duty service or his knee rating. I have reviewed the medical record and it is apparent there is a conflict of testimony from Dr. C.N.B. He stated in October of 2006 the hip pain and the low back pain were secondary to the left knee disorder. I object to Dr. C.N.B.'s opinion based on the fact he is a radiologist. He is not a clinician, in that he does not regularly examine patients or treat them for musculoskeletal disorders. Instead, he is a radiologist that interprets X-rays and radiographs, as well as other diagnostic tests, and it is not possible to examiner a diagnostic test and then accurately predict a degree of pain or impairment. A VA examination in May of 2011 did not find any bilateral hip disability. The records show calcifications surrounding the left hip or trochanter, but this does not relate to a disability. The orthopedic surgeon who examined this patient in January of 2009 recommended total knee arthroplasty, but he also examined his gait, which was recorded as level. He recorded an examination of his hips in January of 2009, which showed painless motion without restriction. Therefore, there is no evidence when examined by an orthopedic surgeon that this patient had an abnormal gait or that he had localized hip tenderness. A bone scan obtained in May 2005 showed increased uptake or evidence of degenerative changes in the right shoulder or AC (acromioclavicluar) joint, also in the hands and feet. There was no increased uptake in the low back or the hips. Therefore, there is no objective evidence that osteoarthritis was present other than the shoulders, hands, and feet. Pre-existing injuries included a fall from a horse in May of 2004, which caused an increase in low back pain, leg pain, and neck pain. There was also a motor vehicle accident in June of 2003 in which the patient was struck from behind while he was sitting in his automobile and he sustained neck and leg pains that gradually responded to therapy. To resolve the contradictory evidence, Dr. C.N.B. opined the bursitis in the hips and the low back pain were the result of left knee disorder or arthritis. However, after reviewing the record, there is no X-ray evidence of degenerative changes in the hips and a bone scan in May of 2005 did not show any increase in uptake in the hips or back. The orthopedic evaluation in January of 2009 did not show hip abnormalities. There is a record of hip tenderness and complaints of left hip pain, but this was shortly after his total knee arthroplasty and prior to his full recovery from the knee arthroplasty. The opinions expressed above are to a reasonable degree of medical probability and are assumed after a review of the medical records provided to me for this opinion. In September 2013, the appellant was provided with a copy of the August 2013 VHA opinion, and he was informed that he had 60 days to review the opinion and send any additional evidence or argument. 38 C.F.R. § 20.903. A. Bilateral Hips, and Left Lower Extremity Under 38 U.S.C.A. § 1110, an appellant must submit proof of a presently existing disability resulting from service in order to merit an award of compensation. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). The Veteran was not treated for any relevant symptoms during service, nor was he noted to have any relevant diagnoses. The Veteran's October 1968 separation examination report shows that his spine, and lower extremities, were clinically evaluated as normal, and the associated "report of medical history" shows that he denied all relevant symptoms. Given the foregoing, the Veteran is not shown to have had a chronic disease during service. See 38 C.F.R. § 3.303(b). Rather, the earliest post-service medical evidence of any relevant findings is dated in 2005 (complaints of hip symptoms), which is about 37 years after separation from service. The U.S. Court of Appeals for the Federal Circuit ("Federal Circuit") has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. Feb. 21, 2013). The Board further finds that the preponderance of the evidence shows that the Veteran does not have either of these claimed conditions. As an initial matter, VA generally does not grant service connection for symptoms which have not been associated with trauma or a disease process. See e.g., Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) ("pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted."); dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). Although there are a number of findings of trochanteric bursitis, and a May 2005 X-ray report noting "minimal symmetric hip DJD," this was prior to the Veteran's filing of his claim in January 2006. McLain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed, or during the pendency of that claim, and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim); Romanowsky v. Shinseki, No. 11-3272 (Vet. App. July 10, 2013) (considering the application of McClain on a recent diagnosis predating the filing of a claim). In addition, there is no X-ray evidence to show the existence of arthritis of either hip that is dated subsequent to the Veteran's filing of his claim, as required by VA regulations. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013); VAGCOPPREC 9-98, 63 Fed. Reg. 56,704 (1998). Here, the more recent, and therefore probative evidence of the Veteran's current condition indicates that he does not have a hip disability. Specifically, the May 2011 VA examination report shows that the examiner stated that there was no objective evidence of a bilateral hip disorder. Associated X-rays of the hips did not reveal any abnormalities. In addition, the August 2013 VHA opinion shows that Dr. D.R.A. discussed the evidence, to include a May 2005 bone scan and a January 2009 orthopedic evaluation, and that he concluded that, "the Veteran does not have a disability of the right or left hip and his complaints of tenderness in the left hip are not related to active duty service or his knee rating." This opinion is considered to be highly probative evidence against the claim, as it is shown to have been based on a review of the Veteran's medical records, and it is accompanied by a sufficient rationale. Neives- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). Accordingly, the Board finds that the preponderance of the evidence shows that the Veteran does not have a hip disability, Gilpin, and is against the claim, and that the claim must be denied. With regard to the claim for left lower extremity sciatica and numbness, the Board similarly finds that this disability is not shown. Gilpin. The May 2011 VA examination report shows that the examiner stated that there was no objective evidence of a sciatic disorder on examination. This opinion is considered to be highly probative evidence against the claim, as it is shown to have been based on a review of the Veteran's medical records, and it is accompanied by a sufficient rationale. Prejean; Neives-Rodriguez. Accordingly, the Board finds that the preponderance of the evidence shows that the Veteran does not the claimed left lower extremity disability, Gilpin, and is against the claim, and that the claim must be denied. In reaching these decisions, the Board has considered the opinion of Dr. C.N.B., dated in October 2006, which shows that he asserted that the Veteran has left leg sciatica, and bilateral hip arthritis, due to his (service-connected) left knee disability. However, he cited to the May 2005 X-ray report, which is dated prior to the Veteran's filing of his claim, which was never corroborated, and which is outweighed by the more recent evidence of record. See e.g., May 2011 VA X-ray report for the hips (noting that there were no abnormalities). In addition, Dr. D.R.A. specifically reviewed Dr. C.N.B.'s report, and found his conclusions unpersuasive, in part, because of Dr. C.N.B.'s lack of pertinent experience. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches). In addition, Dr. D.R.A. concluded that the Veteran did not have a hip disability, although left hip pain was present, and that he did not have a left leg sciatic disorder. Dr. D.R.A. had the benefit of a historical review of the all of the evidence, which made the opinion more informed for the purposes of this adjudication. See Boggs v. West, 11 Vet. App. 334, 344 (1998) (holding that the Board may adjudge a more recent medical opinion to have greater probative value, particularly where the subsequent examiner had additional evidence available in rendering the opinion). Therefore, Dr. C.N.B.'s opinions are insufficiently probative to warrant a grant of either of the claims. B. Low Back Disorder The Board finds that the claim must be denied. The Veteran was not treated for any relevant symptoms during service, nor was he noted to have any relevant diagnoses. The Veteran's October 1968 separation examination report shows that his spine was clinically evaluated as normal, and the associated "report of medical history" shows that he denied all relevant symptoms. Given the foregoing, the Veteran is not shown to have had a chronic disease during service. See 38 C.F.R. § 3.309(b). Rather, the earliest medical evidence of low back symptoms is dated no earlier than 1998, which is many years after separation from service. There is no evidence to show that arthritis of the low back was manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307, 3.309. Furthermore, the May 2011 VA examiner concluded that the Veteran has degenerative changes in his lumbar spine which are commensurate with his age, and which are documented to have begun after a 2003 MVA, and after a fall off of a horse in 2004. He further concluded that the Veteran had normal exercise activity as of 2003, and a normal gait noted in 2005, which would indicate the Veteran's lumbar spine condition was not due to any inability to exercise, or abnormal gait. He stated that the Veteran's lumbar spine disorder is more likely due to the effects of aging coupled with the effects of the 2003 MVA and his fall off of a horse. Similarly, the April 2013 VHA opinion weighs against the claim. Dr. J.M.V.V. noted that the Veteran had two post-service traumas to the spine, and concluded that any diagnosed lumbar spine disorder is not at least as likely as not related to his left knee disability. In reaching this decision, the Board has considered the Veteran's argument that the April 2013 VHA opinion is inadequate because Dr. J.M.V.V. stated that it is difficult to determine a direct connection between lumbar spine degenerative pathology with pain and a service-connected disorder of another weight-bearing joint such as the left knee without an in-person examination. Nevertheless, Dr. J.M.V.V. stated that he was "able to find important information after a careful chart review," and he went on to give a fully rationalized opinion. Therefore, when read in context, the Board has determined that the VHA opinion is sufficient for adjudication of the claim. See Lee v. Brown, 10 Vet. App. 336, 338 (1997) (an etiological opinion should be viewed in its full context, and not characterized solely by the medical professional's choice of words). This opinion, and the May 2011 VA opinion, are considered to be highly probative evidence against the claim, as they are shown to have been based on a review of the Veteran's medical records, and they are accompanied by sufficient rationales. Prejean; Neives-Rodriguez. Accordingly, the Board finds that the preponderance of the evidence is against the claim, and that the claim must be denied. The Board has also considered the opinion of Dr. C.N.B., dated in October 2006, which shows that he asserted that the Veteran has arthritis of the lumbar spine due to an altered gait caused by his (service-connected) left knee disability. However, the Board finds that the opinions of the May 2011 VA examiner, and Dr. J.M.V.V., outweigh Dr. C.N.B.'s opinion, which is over six years old. Both the May 2011 VA examiner and Dr. V had the benefit of a historical review of the all of the evidence, which made the opinions more informed for the purposes of this adjudication. Boggs. Furthermore, Dr. C.N.B. made no effort to explain why he had ruled out the Veteran's trauma to his low back in a 2003 MVA, or a fall off of a horse in 2004, as the cause of the Veteran's low back disorder; he did not discuss these events whatsoever. Neives-Rodriguez. Finally, the Board notes that Dr. D.R.A.'s opinion also takes issue with Dr. C.N.B.'s conclusion, noting that the Veteran's May 2005 bone scan did not reveal increased uptake in the back. Therefore, Dr. C.N.B.'s opinion is insufficiently probative to warrant a grant of the claim. C. Heart Disability, Including Hypertension The Board finds that the claim must be denied. The Veteran was not treated for any relevant symptoms during service, nor was he noted to have any relevant diagnoses. The Veteran's October 1968 separation examination report shows that his heart was clinically evaluated as normal, and the associated "report of medical history" shows that he denied all relevant symptoms. Given the foregoing, the Veteran is not shown to have had a chronic disease during service. See 38 C.F.R. § 3.309(b). However, the Veteran's atrial fibrillation is arguably among the conditions listed at 38 C.F.R. § 3.309(a), as an "organic heart disease." Therefore, affording the Veteran all reasonable doubt, the theory of continuity of symptomatology applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). But atrial fibrillation is not shown until December 2003, which is about 35 years after separation from service. Therefore, service connection on a presumptive basis is therefore not warranted. 38 C.F.R. §§ 3.307, 3.309. And as is discussed below in more detail, the preponderance of the evidence is against any connection between service and atrial fibrillation. With regard to hypertension, this is not shown prior to 2001, which is about 33 years after separation from service. Therefore, service connection on a presumptive basis is therefore not warranted. 38 C.F.R. §§ 3.307, 3.309. The Board further finds that the May 2011 VA examiner's opinions are highly probative evidence against the claims, as they are shown to have been based on a review of the Veteran's medical records, and they are accompanied by sufficient rationales. Neives- Rodriguez; Prejean. Accordingly, the Board finds that the preponderance of the evidence shows that the Veteran's hypertension, and atrial fibrillation, are not related to his service. With regard to the possibility of secondary service connection, the Board finds that the May 2011 VA examiner's opinions are highly probative evidence against the claims, as they are shown to have been based on a review of the Veteran's medical records, and they are accompanied by sufficient rationales. 38 C.F.R. § 3.310; Neives- Rodriguez; Prejean. Accordingly, the Board finds that the preponderance of the evidence shows that the Veteran's hypertension, and atrial fibrillation, were not cause, or aggravated, by a service-connected disability, and that the claims must be denied. In reaching these decisions, the Board has considered the opinion of Dr. C.N.B., dated in October 2006, which shows that he asserted that the Veteran has heart condition due to his (service-connected) left knee disability, because "he has been unable to exercise and therefore is forced sedentary lifestyle likely significantly contributed to his current cardiac disease as it is well-documented in literature that sedentary lifestyles have a causal connection to cardiac disease." However, he did not cite to any literature or studies in support of his claim. In addition, subsequently-dated medical evidence indicates that the Veteran is indeed able to exercise. See October 20008 report from G.V.B., M.D. (noting that the Veteran denied pain or swelling while walking); April 2009 report from Tennessee Orthopedic (noting that the Veteran was working out at the gym with a personal trainer, mainly using his upper extremities, but also exercising on a bicycle 15 minutes every other day). Finally, as noted by the May 2011 VA examiner, the Veteran stated that he had no restrictions on his ability to exercise as of 2001, at which time he was treated for essential hypertension, and that he did not develop atrial fibrillation until December 2003. The May 2011 VA examiner's opinion weighs against the claim; he had the benefit of a historical review of the all of the evidence, which made the opinion more informed for the purposes of this adjudication. Boggs. Therefore, Dr. C.N.B.'s opinion is insufficiently probative to warrant a grant of the claim. D. Conclusion With regard to the Veteran's own contentions, a layperson is generally not capable of opining on matters requiring complex medical knowledge. Lay testimony is competent, however, to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). The issues on appeal are based on the contentions that a right hip disorder, a left hip disorder, a lumbar spine disorder, a heart disorder (to include hypertension), and left lower extremity sciatica and numbness, were caused by service. 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 issues in this case, these fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The medical records have been discussed. The Board has determined that bilateral hip, and a left lower extremity disorder, are not shown, and that the Veteran's hypertension, heart disorder, and low back disorder, are not related to his service, or to a service-connected disability. Given the foregoing, the Board finds that the medical evidence outweighs the Veteran's contentions to the effect that a right hip disorder, a left hip disorder, a lumbar spine disorder, a heart disorder (to include hypertension), and left lower extremity sciatica and numbness, were caused by service, or are related to a service-connected disability. The Board notes that the Veteran has claimed that he was exposed to Agent Orange during service near the demilitarized zone in Korea between January 1967 and January 1968. See Veteran's statement (VA Form 21-4138), received in August 2011. However, this is not within the time period for which exposure to Agent Orange is conceded for members of certain units serving in Korea, i.e., April 1968 and July 1969. See VA Adjudication Procedure Manual (M21-1) pt. IV, subpt. ii, ch. 2, sec. C, 10, p. In addition, even assuming arguendo that exposure to Agent Orange was established, there is no competent evidence to show that any of the claimed conditions are related to such exposure, Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994), and the applicable law does not include any of the claimed disorders as a condition for which presumptive service connection may be granted on this basis. See 38 U.S.C.A. § 1116 (West 2002); 38 C.F.R. §§ 3.307(a)(6) , 3.309(e). In this regard, there are notations by history of coronary artery disease, but these are dated prior to the Veteran's filing of his claim. McLain. Atherosclerotic and coronary artery disease are not currently shown. Therefore, service connection for a heart disorder, or hypertension, may not be granted on this basis. The Board therefore finds that the preponderance of the evidence is against the claims for service connection, and that the claims must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Duties to Notify and Assist The Board finds that the duties to notify have been fulfilled by information provided to the Veteran in a letter from the RO dated in November 2006 (left hip) and November 2006 (heart, bilateral hips, and lumbar spine). 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). These letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claims, and identified the Veteran's duties in obtaining information and evidence to substantiate his claims. 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess/Hartman v. Nicholson, 20 Vet. App. 473 (2006); Mayfield v. Nicholson, 20 Vet. App. 537 (2006). The RO also provided assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service medical reports, and post-service records relevant to the issues on appeal have been obtained and are associated with the Veteran's claims files. The RO has obtained the Veteran's service treatment records, VA and non-VA medical records. In this regard, in March 2010, the RO issued a memorandum in which it detailed the attempts that had been made to obtain the Veteran's service treatment reports (other than those already associated with the claims file) from the Martin Army Community Hospital (MACH). The RO concluded that all attempts to obtain additional service treatment reports had been correctly followed, that all efforts to obtain the needed military information had been exhausted, and that any further attempts are be futile and that based on these facts, the record is not available. That same month, the RO notified that Veteran and his representative that service treatment reports from MACH could not be found. See 38 C.F.R. § 3.159(e) (2013). The Veteran has been afforded examinations, and etiological opinions have been obtained for all relevant diagnosed conditions. In May 2011, this was done, and two VHA opinions were subsequently obtained. Under the circumstances, the Board finds that there has been substantial compliance with its remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). In April 2009, the Veteran was provided an opportunity to set forth his contentions during a hearing before the undersigned. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims recently held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the April 2009 hearing, the undersigned identified the issues on appeal. Also, information was solicited regarding the claimed etiology of his disabilities. The testimony did not reflect that there were any outstanding medical records available that would support his claims. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. The Veteran and his representative have not argued that any error or deficiency in the accomplishment of the duty to notify has prejudiced him in the adjudication of his appeal. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination). In view of the above, the Board finds that the notice requirements pertinent to the issues on appeal have been met. In summary, the Board finds that the available medical evidence is sufficient for an adequate determination of the claims on appeal. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with these claims does not cause any prejudice to the Veteran. ORDER Service connection for a right hip disorder, a left hip disorder, a lumbar spine disorder, a heart disorder, and left lower extremity sciatica and numbness, is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs