Citation Nr: 1340258 Decision Date: 12/05/13 Archive Date: 12/20/13 DOCKET NO. 05-04 167 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for a back disorder, to include as secondary to service-connected Pellegrini-Stieda of the left knee and/or Osgood-Schlatter's disease of the right knee. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESSES AT HEARINGS ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD A.M. Ivory, Counsel INTRODUCTION The Veteran had active military service from August 1971 to April 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which determined that new and material evidence had not been received in order to reopen the Veteran's claim for service connection for right nerve root compression of the lumbar spine. The new and material issue was previously before the Board in November 2006. At such time, it was remanded in order to afford the Veteran his requested hearing before a Decision Review Officer (DRO). As such, the Veteran and his spouse testified at a March 2007 hearing before a DRO at the RO regarding his application to reopen his claim of entitlement to service connection for nerve root compression of the lumbar spine. They also testified in July 2012 before the undersigned Veterans Law Judge sitting at the RO regarding such issue on appeal. Transcripts of both hearings are associated with the claims file. In November 2012, the Board reopened the Veteran's claim and remanded it for further development. In May 2013 and August 2013, the Board again remanded the Veteran's claim for service connection for a back disorder for additional development. Such case now returns for final appellate review. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the Virtual VA claims file reveals VA treatment records dated through August 2012, which were considered by the agency of original jurisdiction (AOJ) in the April 2013 supplemental statement of the case. FINDING OF FACT A back disorder is not related to any disease, injury, or incident of service, did not manifested within one year of service discharge, and was not caused or aggravated by the Veteran's service-connected Pellegrini-Stieda of the left knee and/or Osgood-Schlatter's disease of the right knee. CONCLUSION OF LAW A back disorder was not incurred in or aggravated by the Veteran's active duty military service, may not be presumed to have been incurred in or aggravated by such service, and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2006), (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist 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 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) 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. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a January 2003 letter, sent prior to the initial unfavorable decision issued in July 2003, and a January 2013 letter advised the Veteran of the evidence and information necessary to substantiate his service connection claim, to include on a secondary basis, as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, the January 2013 letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. While the January 2013 letter was issued after the initial July 2003 rating decision, the United States Court of Appeals for the Federal Circuit has held that VA could cure such a timing problem by readjudicating the Veteran's claim following a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006). The Court clarified that the issuance of a statement of the case could constitute a readjudication of the Veteran's claim. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after the January 2013 letter was issued, the Veteran's claim was readjudicated in the April 2013 and July 2013 supplemental statements of the case. Therefore, any defect with respect to the timing of the VCAA notice has been cured. Relevant to the duty to assist, the Veteran's service treatment records as well as post-service VA and private treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. In this regard, the Board notes that the Veteran has identified additional treatment at Hunt County Mental Health Services and Greenwell Memorial Hospital. While the January 2013 letter requested that he provide authorization for VA to obtain any private treatment records, to include those located at such facilities, the Veteran did not do so. The Board emphasizes that the duty to assist is not always a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Moreover, in an October 2013 statement, the Veteran indicated that all of his treatment records had been forwarded to VA. Therefore, the Board finds that VA has satisfied its duty to assist in this regard. The Veteran was also afforded VA examinations in February 2008, March 2013, April 2013, and June 2013, and a VA medical opinions was rendered in September 2013. While the physical examinations detailing the findings involving the Veteran's back are adequate to determine the nature of such disorder, the February 2008, March 2013, and April 2013 opinions are not adequate to decide the claim. Specifically, the February 2008 VA examiner opined that that his back disorder was less likely than not related to the Veteran's service as his service treatment records were negative for treatment for his back. However, the service treatment records show a complaint of back pain and treatment for muscle spasms after a motor vehicle accident. Moreover, the February 2008 VA examiner did not offer an opinion regarding the secondary aspect of the Veteran's claim. Additionally, the March 2013 VA examiner did not offer an opinion and, in April 2013, incorrectly provided an opinion and rationale regarding whether or not the Veteran's bilateral knee disability, which is already service-connected, was as a result of his low back disorder, the Board finds that such opinions to be inadequate to decide the claims. However, the Board finds that the June 2013 and September 2013 VA opinions are adequate to decide the issue as they are predicated on a review of the record, which includes reports of interviews with the Veteran as well as his statements and testimony at hearings; a review of his medical record, to include his service treatment records; and a review of previous VA examination with physical findings and diagnostic testing. The opinions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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"). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the issue decided herein has been met. As indicated previously, in November 2006, November 2012, May 2013, and August 2013 the Veteran's claim was remanded for further development. The November 2006 remand directed that the Veteran be afforded his requested DRO hearing, which was held in March 2007. Additionally, the November 2012 remand ordered that the Veteran be provided with VCAA pertaining to the secondary aspect of his claim, which was accomplished by way of a January 2013 letter. Such remand further directed that the Veteran be afforded an opportunity to identify any outstanding treatment records referable to his back, which was likewise addressed by the January 2013 letter, and, thereafter, all identified records, to include those from at Hunt County Mental Health Services, Greenwell Memorial Hospital, and Texas VA facilities dated from May 11, 2010, to the present, be obtained. While VA treatment records dated through August 2012 have been associated with the record, the Veteran did not provide proper authorization for VA to obtain the private treatment records. See Wood, supra. Finally, the November 2012 remand directed that the Veteran be afforded a VA examination in order to determine the nature and etiology of his back disorder, which was accomplished in March 2013 and April 2013. However, as such opinions are inadequate, as discussed previously, the May 2013 remand directed that an addendum opinion be obtained. Such was accomplished in June 2013; however, as the Board still required additional information, the case was again remanded for another opinion from a different examiner in August 2013 and another addendum opinion was obtained in September 2013. Therefore, the Board finds that the AOJ has substantially complied with the November 2006, November 2012, May 2013, and August 2013 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Additionally, in March 2007 and July 2012, the Veteran was provided an opportunity to set forth his contentions during a hearing before a DRO and the undersigned Veterans law Judge, respectively. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the DRO or Veterans Law Judge 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. The Veteran testified at a DRO hearing in March 2007 and at a Board hearing before the undersigned Veterans Law Judge in July 2012. At both hearings the DRO and the Veterans Law Judge noted the issue on appeal. Also, information was solicited regarding the Veteran's in-service experiences he alleges resulted in his back disorder and his contention that his military service caused such disorder. Furthermore, at the July 2012 Board hearing, testimony regarding the impact his service-connected knee conditions have on his back disorder was obtained. 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, as the Veteran identified additional evidence at the hearings and such testimony gave rise to the need for medical inquiry into the nature and etiology of his back disorder, the Board remanded this case in November 2012, May 2013, and August 2013 so as to obtain all outstanding records as well as medical opinions regarding the etiology of the Veteran's back disorder. Under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran's claim decided herein. As such, the Board finds that, consistent with Bryant, the DRO and the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claim decided herein based on the current record. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); 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 appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, to include arthritis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In some cases, service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. The Board notes that the provisions of 38 C.F.R. § 3.310 were amended during the pendency of the Veteran's appeal, effective October 10, 2006; however, the new provisions state that service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Although the stated intent of the change was merely to implement the requirements of Allen, supra, the Board finds that the new provisions amount to a substantive change to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the Veteran as it does not require the establishment of a baseline level of disability before an award of service connection may granted. See generally, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Veteran asserts that his current back disorder is related to his military service or, in the alternative, caused or aggravated by his service-connected Pellegrini-Stieda of the left knee and/or Osgood-Schlatter's disease of the right knee. At both of his hearings and in documents of record, the Veteran testified that he had experienced back pain since service. At his July 2012 Board hearing, he further indicated that his bilateral knee disabilities caused him to alter his gait, thus causing or aggravating his back disorder. However, after a careful review of the Veteran's claims file the Board finds that service connection must be denied on both a direct and secondary basis. The Veteran's service treatment records include a December 1971 clinic evaluation that noted his report of back pain in conjunction with additional complaints of sore throat, chest pain and tachycardia. He was given assessments of tachycardia by history and multiple psychosomatic complaints. A March 1972 service treatment record reflects that the Veteran was involved in an automobile accident with a loss of consciousness for four hours. Pain in the left parietal and left tibial areas was noted and there was an impression of muscle spasm. The Veteran was instructed to return as needed for "neck pain." On his March 1972 Report of Medical History for Separation, he denied a history of recurrent back pain and his March 1972 Report of Medical Examination for Separation revealed a normal clinical evaluation of the spine. The Veteran's post-service records include an October 1978 VA clinic record that noted an episode of his right knee giving-way and locking. An October 1978 private treatment record noted that he reported low back pain with x-ray findings of a normal lumbosacral spine. In December 1983 a private hospitalization record noted that he had a history of low back pain for "quite some time" with an additional back injury at work. His discharge diagnosis was low back pain syndrome with muscle spasm, degenerative disc disease, and L4 radiculopathy. A June 1984 private medical statement noted his treatment for a September 1983 work-related injury which caused incapacitating pain. The Veteran was afforded a VA examination in February 2008 at which time the VA examiner opined that that his back disorder was less likely than not related to the Veteran's service as his service treatment records were negative for treatment for his back. The Veteran reported that he had an in-service lifting injury. At the VA examination he was diagnosed with myofascial lumbar syndrome. In March 2013, the Veteran was afforded another VA examination, at which time lumbar spondylosis and lumbar sprain were diagnosed. A VA examiner opined in June 2013 that the Veteran's current back disability, diagnosed as chronic degenerative changes, was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale for such opinion, the examiner stated that it was more likely than not that the Veteran's current lumbar spine condition was due to chronic degenerative changes associated with aging and morbid obesity and indicated that, based on the available medical documentation, he was unable to comment further without resorting to mere speculation. The June 2013 VA examiner likewise opined that the back disability was less likely than not proximately due to or the result of the Veteran's service-connected condition. As rationale for such opinion, the examiner stated that a review of the orthopedic literature reveals no credible, peer-reviewed studies that support the contention that degenerative changes of one joint may induce degenerative changes in another joint either of the affected or contralateral extremity or spine, even in the setting of leg length discrepancy. He further indicated that it was more likely than not that the Veteran's current lumbar spine condition was due to chronic degenerative changes associated with aging and morbid obesity and indicated that, based on the available medical documentation, he was unable to comment further without resorting to mere speculation. In September 2013, a VA medical opinion was rendered. The examiner stated that there was no evidence of a chronic back condition on active duty and there were no complaints or treatment related to an intrinsic back condition. He further indicated that there was one complaint related to the back when the Veteran was seen in December 1971 for a sore throat, chest pain/tachycardia, and nausea but there was no evidence of any further complaints or treatment. There was also no evidence of any complaints related to the Veteran's back the day after his 1972 motor vehicle accidents and there was no evidence of any back abnormalities on his May 1972 separation examination. The VA examiner concluded that the Veteran's back condition was not related to his military service nor was it caused by his reported motor vehicle accident. The examiner further stated that there is nothing in the currently accepted, peer reviewed, credible, and authoritative orthopedic literature that supports the contention that intrinsic knee conditions (with or without altered gait pattern; with or without altered surgical intervention, etc.) would cause intrinsic conditions of the spine. He opined that the current lumbar spine condition was not secondary to his bilateral knee conditions. He also stated that there was no evidence found in the Veteran's service treatment records or claims file that the bilateral knee has aggravated (as defined for VA purposes) the back condition. He further stated that the current spine condition is/was not aggravated (as defined for VA purposes) by the bilateral knee condition. He concluded that based on the review of the claims file it was his opinion that his spine condition was more likely due to the normal process of attrition and aging and/or the documented work injury(ies)/complaint(s) noted in the record and/or a predisposition to a back condition and not related to military service or to the reported motor vehicle accident. The Board will initially address the adequacy of the VA examinations and the probative weight to be assigned to the opinions of record. In this regard, the Board notes that the February 2008 VA examiner opined that that the Veteran's back disorder was less likely than not related to the Veteran's service as his service treatment records were negative for treatment for his back. However, the service treatment records show a complaint of back pain and treatment for muscle spasms after a motor vehicle accident. Therefore, such opinion is inadequate to decide the claim as it is based on an inaccurate factual premise. Moreover, the March 2013 VA examiner did not offer an opinion and, in April 2013, incorrectly provided an opinion and rationale regarding whether or not the Veteran's bilateral knee disability, which is already service-connected, was as a result of his low back disorder. Therefore, the Board likewise finds that such opinions to be inadequate to decide the claim and are accorded no probative weight. Additionally, the Board notes that the June 2013 VA examiner opined that the Veteran's current back disability, diagnosed as chronic degenerative changes, was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale for such opinion, the examiner stated that it was more likely than not that the Veteran's current lumbar spine condition was due to chronic degenerative changes associated with aging and morbid obesity and indicated that, based on the available medical documentation, he was unable to comment further without resorting to mere speculation. However, the VA examiner did not explain how he arrived at this conclusion or discuss the significance, if any, of the Veteran's report of back injury and recurrent low back pain since service. Therefore, such portion of the June 2013 VA examiner's opinion is inadequate to decide the claim and is accorded no probative weight. However, the Board finds that the June 2013 VA examiner's opinion regarding whether the Veteran's bilateral knee disability caused his back disorder as well as the September 2013 VA examiner's opinion pertaining to both the direct and secondary aspect of the Veteran's claim to be highly probative. In this regard, both VA examiners as they reviewed the record, which includes reports of interviews with the Veteran as well as his statements and testimony at hearings; reviewed his medical record, to include his service treatment records; and reviewed previous VA examination with physical findings and diagnostic testing. The opinions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Therefore, the Board accords great probative weight to such opinions. Moreover, there are no medical opinions to the contrary. The Board initially finds that the Veteran's claim must be denied on a direct basis. First, there was only complaint of back pain in his service treatment records and it was in relation to sore throat, chest pain and tachycardia. He was never diagnosed with a back condition during service and there were no additional complaints or treatment of a back condition during service. At the time of his separation, the Veteran did not report any back condition and his spine was found to be normal on examination. Secondly, the first notation of any back pain was in October 1978 with examination revealing a normal spine. Additionally, in December 1983, after a post-service injury, it was noted that the Veteran had back pain for some time but it was not specified for how long. Thus, the first notation of any back pain was six years after service and the first diagnosis was 12 years after service. Evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Moreover, even though the Veteran reported pain in 1978, his spine was normal on examination. Pain alone, without a diagnosed or identifiable underlying malady or condition, does not constitute a disability for which service connection can be granted. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). In addition to the Veteran's service treatment records being silent for any treatment or diagnosis of a back disorder and that he did not report any back pain until October 1978, the Board finds that the probative medical opinions of record are against the Veteran's claim on a direct basis. Specifically, the highly probative September 2013 VA examiner's opinion determined that there was no evidence of a chronic back condition on active duty and there were no complaints or treatment related to an intrinsic back condition. He further indicated that there was one complaint related to the back when the Veteran was seen in December 1971 for a sore throat, chest pain/tachycardia, and nausea but there was no evidence of any further complaints or treatment. There was also no evidence of any complaints related to the Veteran's back the day after his 1972 motor vehicle accidents and there was no evidence of any back abnormalities on his May 1972 separation examination. The VA examiner concluded that the Veteran's back condition was not related to his military service nor was it caused by his reported motor vehicle accident. Therefore, based on the foregoing, to specifically include the highly probative September 2013 VA examiner's opinion, the Board finds that service connection for a back disorder on a direct basis is not warranted. Furthermore, the Board finds that service connection for a back disorder as secondary to the Veteran's service-connected bilateral knee disabilities must be denied. In this regard, the highly probative June 2013 VA examiner's opinion determined that the Veteran's back disability was less likely than not proximately due to or the result of the Veteran's service-connected condition. As rationale for such opinion, the examiner stated that a review of the orthopedic literature reveals no credible, peer-reviewed studies that support the contention that degenerative changes of one joint may induce degenerative changes in another joint either of the affected or contralateral extremity or spine, even in the setting of leg length discrepancy. He further indicated that it was more likely than not that the Veteran's current lumbar spine condition was due to chronic degenerative changes associated with aging and morbid obesity and indicated that, based on the available medical documentation, he was unable to comment further without resorting to mere speculation. Moreover, the highly probative September 2013 VA examiner's opinion further stated that there is nothing in the currently accepted, peer reviewed, credible, and authoritative orthopedic literature that supports the contention that intrinsic knee conditions (with or without altered gait pattern; with or without altered surgical intervention, etc.) would cause intrinsic conditions of the spine. He opined that the current lumbar spine condition was not secondary to his bilateral knee conditions. He also stated that there was no evidence found in the Veteran's service treatment records or claims file that the bilateral knee has aggravated (as defined for VA purposes) the back condition. He further stated that the current spine condition is/was not aggravated (as defined for VA purposes) by the bilateral knee condition. He concluded that based on the review of the claims file it was his opinion that his spine condition was more likely due to the normal process of attrition and aging and/or the documented work injury(ies)/complaint(s) noted in the record and/or a predisposition to a back condition and not related to military service or to the reported motor vehicle accident. Therefore, based on the foregoing, to specifically include the highly probative June 2013 and September 2013 VA examiners' opinions, the Board finds that service connection for a back disorder on a secondary basis is not warranted. The Board observes that it is unclear whether the Veteran has a current diagnosis of arthritis of the spine. In this regard, in December 1983, he was diagnosed with degenerative disc disease and a March 2013 x-ray study revealed multilevel anterolateral osteophytes with no other significant degenerative changes. However, the June 2013 VA examiner noted that the Veteran's back disorder was currently diagnosed as chronic degenerative changes. Therefore, the Board has considered whether service connection for arthritis of the back on a presumptive basis is warranted. In this regard, the evidence does not show that arthritis of the spine manifested within one year of his service discharge in April 1972. Rather, the first complaint of back pain was in October 1978 and x-ray findings at that time revealed a normal lumbosacral spine. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Moreover, the Board notes the Veteran's assertions that he has experienced a continuity of back pain since service. The Board retains the discretion to determine the credibility and weight of all the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). However, as discussed below, the Board finds that the Veteran's statements are contradictory and are not deemed credible; thus, presumptive service connection for arthritis of the spine cannot be established on the basis of continuity of symptomatology. See Walker, supra. While the Veteran was treated for back pain during service, it was in relation to a diagnosis of tachycardia and psychosomatic complaints. In addition, he did not report back pain on his March 1972 Report of Medical History for Separation. Moreover, his spine was found to be clinically normal on his separation examination. Furthermore, it is pertinent to note that the Veteran never gave his medical care providers a history of having a back disorder either since service or due to service until February 2008 (after he filed his claim for service connection). Moreover, when he reported low back pain to his private physician in October 1978, he did not mention his military service and when he sought treatment for back pain in December 1983, it was in reference to a post-service September 1983 injury. Lay statements made when medical treatment was being rendered may be afforded greater probative value. These 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. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that, although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate; 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). See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). In light of evidence as noted above, the Board has to question the credibility of the Veteran's current contentions. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statement, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony). The Board finds that the Veteran's current assertions of experiencing a back disorder during and since service are not credible and, thus, are entitled to no probative weight. In this regard, the record reflects that the Veteran only reported that his back disorder was due to service after filing his claim for service connection. Furthermore, the Veteran's service treatment records indicate that he denied any chronic back disorder at separation of service, which is in direct conflict with the Veteran's post-service statements that his symptomatology continued since his in-service fall and motor vehicle accident. As such, the Veteran's recent lay assertions lack credibility because they are contradicted by notations in objective records reflecting his contemporaneous reports pertinent to a back disorder. In light of these contradictory statements, any current assertions as to experiencing a back disability since service, advanced in furtherance of the appeal, are deemed not credible. Consequently, presumptive service connection for arthritis of the spine, to include on the basis of continuity of symptomatology, is not warranted. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. The Board has also considered the Veteran's lay assertions that his current back disorder is either directly related to his military service or secondary to his service-connected bilateral knee disabilities; however, as a lay person, he is not competent to render such a complex medical opinion. In this regard, he is competent to describe an in-service injury, such as a fall or motor vehicle accident, as well as his current back pain; however, as the cause of such a disability involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, he is not competent to render such a complex medical opinion. In this regard, diagnosing a back disorder and determining the etiology of such involves examination and specialized testing, as well as knowledge of the result of trauma to the spine. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also 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). Therefore, the Board finds that service connection for a back disorder is not warranted on a direct, secondary, or presumptive basis. 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 Veteran's claim of entitlement to service connection for a back disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for a back disorder is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs