Citation Nr: 1417391 Decision Date: 04/17/14 Archive Date: 05/02/14 DOCKET NO. 06-21 488A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for peripheral neuropathy of the right upper extremity, including as due to herbicide exposure or service-connected diabetes mellitus. 2. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, including as due to herbicide exposure or service-connected diabetes mellitus. 3. Entitlement to service connection for a right knee disability, including as due to herbicide exposure or service-connected diabetes mellitus. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.M. Seay, Counsel INTRODUCTION The Veteran served on active duty from August 1967 to March 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from September 2005 and October 2006 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified at a Travel Board hearing in June 2009 before the undersigned Veterans Law Judge and a copy of the hearing transcript is associated with the claims file. In August 2011, the Board issued a decision that, in part, denied the claims of entitlement to service connection for peripheral neuropathy of the right upper extremity, including as due to herbicide exposure or service-connected diabetes mellitus, entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, including as due to herbicide exposure or service-connected diabetes mellitus, and entitlement to service connection for a right knee disability, including as due to herbicide exposure or service-connected diabetes mellitus. The Board points out that entitlement to service connection for ulnar nerve entrapment of the left upper extremity was granted by the Board's August 2011 decision and, therefore, that portion of the decision remains undisturbed. Pursuant to a settlement agreement in the case of National Org. of Veterans' Advocates, Inc. v. Secretary of Veterans Affairs, 725 F.3d (Fed. Cir. 2013), the Board's August 2011 decision was identified as having been potentially affected by an invalidated rule relating to the duties of the VLJ that conducted the June 2009 hearing. In order to remedy any such potential error, the Board sent the Veteran a letter notifying him of an opportunity to receive a new hearing and/or a new decision from the Board. Subsequently, the Veteran requested only to have the prior decision vacated and a new one issued in its place. This decision satisfies that request. FINDINGS OF FACT 1. The Veteran's service personnel records show that he served in the Republic of Vietnam between January 1968 and March 1969; therefore, he is presumed to have been exposed to herbicide agents, to include Agent Orange. 2. The most probative and competent evidence shows that the Veteran does not experience any disability due to peripheral neuropathy in his right upper extremity. 3. The most probative and competent evidence shows that the Veteran does not experience any disability due to peripheral neuropathy in his bilateral lower extremities. 4. The most probative and competent evidence shows that the Veteran's current right knee disability is not related to active service or his service-connected diabetes mellitus. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral neuropathy of the right upper extremity are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1137, 1154, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 2. The criteria for service connection for peripheral neuropathy of the bilateral lower extremities are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1137, 1154, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 3. The criteria for service connection for a right knee disability are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1137, 1154, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA letters issued in November 2004, May 2005, May 2006, and July 2010 cumulatively satisfied the duty to notify provisions with respect to service connection. The May 2006 letter notified the Veteran of the regulations pertinent to the establishment of an effective date and disability rating. With respect to any letter sent after the initial adjudication of the claims, the claims were readjudicated by a May 2011 supplemental statement of the case. Therefore, any defect in the timing of the notice of this information was harmless. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). The Veteran's service treatment records and VA medical treatment records have been obtained and associated with the claims file. The Veteran does not contend and the evidence does not show that he is in receipt of Social Security Administration (SSA) disability benefits such that a remand to obtain his SSA records is required. The Veteran was provided VA examinations in September 2006 and January 2011. The Board finds the examinations are adequate as the examiners reviewed the claims file, examined the Veteran, and provided the necessary information regarding the issues on appeal. With respect to any opinion regarding the etiology of peripheral neuropathy, such is not required as the most probative and competent evidence does not reflect a diagnosis of peripheral neuropathy at any point during the appeal period or in proximity to the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The Board notes that the January 2011 examiner did not provide an opinion as to whether diabetes mellitus aggravated the Veteran's right knee disability. 38 C.F.R. § 3.310. However, a remand for a new opinion is not required. The examiner opined that he could not see how the Veteran's diabetes mellitus "in any way could cause" his current right knee osteoarthritis. Due to the examiner's unequivocal language, the Board finds that a remand for an opinion as to aggravation is not required. The Board acknowledges that an October 2007 VA treatment record included an assessment of ulnar neuropathy of the right upper extremity. In December 2007, an EMG was normal. An opinion as to the etiology of any ulnar neuropathy is not required. First, there is no competent evidence relating ulnar neuropathy to the Veteran's service-connected diabetes mellitus. The September 2006 VA examiner did not diagnose ulnar neuropathy; however, the examiner addressed the symptoms in the right forearm and explained that these were not manifestations related to diabetes mellitus. While the September 2006 examiner stated specifically: "this condition is consistant with any known complication of diabetes mellitus and predates the DM by at least 18 months," it is evident that the examiner intended to state that the disability was "inconsistent" as opposed to "consistent." Indeed, at the conclusion of the report, the examiner was directed to state etiology and the examiner noted "Not diabetes mellitus." Thus, the Board finds the opinion adequate to adjudicate the issue of entitlement to secondary service connection and an additional opinion regarding any relationship between diabetes mellitus and any ulnar neuropathy is not required. Further, an opinion as to direct service connection is not required. The service treatment records are absent for any symptoms related to neuropathy. While the Veteran reported symptoms since active service, the Board does not find the Veteran to be an accurate or credible historian. The Veteran was examined shortly after separation from active service in 1973 and there was no indication of symptoms or manifestations related to neuropathy. While the Veteran may believe his ulnar neuropathy is related to active service, he is not competent to provide such an opinion as this is a complex medical question. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Therefore, an opinion as to a relationship between ulnar neuropathy and active service is not required. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the hearing, the VLJ noted the basis of the prior determination and the element of the claims that was lacking to substantiate the claims for benefits. The VLJ identified the issues as service connection for peripheral neuropathy of the bilateral upper extremities and of the bilateral lower extremities and for a right knee disability, each including as due to herbicide exposure or service-connected diabetes mellitus. The Veteran was assisted at the hearing by an accredited representative from the Texas Veterans Commission. The representative and the VLJ asked questions to ascertain whether the Veteran submitted evidence in support of these claims. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims file that might have been overlooked or was outstanding that might substantiate the claims. The representative specifically asked the Veteran about continuity of the Veteran's peripheral neuropathy and right knee symptomatology since active service. The hearing focused on the element necessary to substantiate the claims and the Veteran, through his testimony, demonstrated that he had actual knowledge of the element necessary to substantiate his claims for benefits. The Veteran's representative and the VLJ asked questions to draw out the evidence which related the Veteran's peripheral neuropathy of the bilateral upper extremities and of the bilateral lower extremities and his right knee disability to active service, the only element of the claims in question. In addition, with respect to service connection on a secondary basis, the representative noted that there was an inferred claim for such. The VLJ discussed the claim for service connection for peripheral neuropathy as related to diabetes mellitus. With respect to the right knee claim as secondary to diabetes mellitus, while this was not specifically discussed during the hearing, the supplemental statement of the case explained why service connection was not warranted on a secondary basis and included the elements necessary to establish secondary service connection. The July 2010 notice letter identified the issue as including secondary service connection. To the extent that there was any notice error during the hearing, the Board finds no prejudice to the Veteran as he was informed of the issues on appeal, the elements required to substantiate the issues on appeal, and provided several opportunities to identify and/or submit evidence related to the issues on appeal. Legal Criteria 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 means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. 38 C.F.R. § 3.303(a). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). In the case of any Veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. Reasonable doubt shall be resolved in favor of the Veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). A Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, specifically: 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram. If a Veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. These diseases include: AL amyloidosis, chloracne or other acneform disease consistent with chloracne, Type 2 diabetes, Hodgkin's disease, Ischemic heart disease, all chronic B-cell leukemias, Multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, Early onset peripheral neuropathy, Porphyria cutanea tarda, Prostate cancer, Respiratory cancers, and Soft-tissue sarcoma. Under the VA's recently amended regulations, symptoms of early onset peripheral neuropathy no longer need to be transient, and appear "within weeks or months of exposure" and resolve within two years of the date of onset for the presumption of service connection due to herbicide exposure to apply. Peripheral neuropathy will still need to become manifest to a degree of 10 percent or more within one year after the date of last exposure to herbicides in order for a veteran to qualify for the presumption. See 78 Fed. Reg. 54,763 (September 6, 2013). Service connection also may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition also is compensable under 38 C.F.R. § 3.310(a). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Peripheral Neuropathy The Veteran asserts that he is entitled to service connection for peripheral neuropathy of the right upper extremity and bilateral lower extremities. On examination in September 2006, the Veteran complained of pain in the right forearm and pain from his lower back to his right foot and the posterior aspect of the right leg for the previous five years. He reported weakness in both the right upper and lower extremities. The examiner reviewed the claims file. The Veteran had an antalgic gait and used a cane and a knee brace. Sensation was normal in the bilateral lower extremities. There was slightly decreased sensation of the skin in the C7 dermatome of the forearm although the Veteran had normal sensation distally in the same dermatome. Motor strength was 5/5 in all extremities. There were no physical abnormalities found in the nerves other than the Veteran's subjective complaints and an inconsistent sensory examination. The examiner stated that the Veteran had subjective numbness in the right forearm with an inconsistent physical examination and was unable to make a diagnosis for peripheral neuropathy based on history and physical examination alone. The examiner noted that the Veteran's complaint of peripheral neuropathy pre-dated his diabetes mellitus by at least 18 months. The examiner explained that the Veteran's complaint of subjective pain of the right lower extremity was not consistent with a complication of diabetes mellitus and also pre-dated the diabetes mellitus by 18 months. He concluded that the etiology of the claimed peripheral neuropathy was not diabetes mellitus. The assessment was that peripheral neuropathy of the bilateral lower extremities was not found on examination. In an October 2007 VA treatment record, the Veteran complained of numbness in the right upper extremity, notably in the right fourth and fifth digits. He reported a history of numbness in the right foot, specifically in the heel region, but denied any right foot weakness. Objective examination of the right upper extremity showed that the Veteran's symptoms were reproduced in the fourth and fifth digits with elbow flexion. The assessment included ulnar neuropathy. An EMG of the Veteran's upper extremities in December 2007 showed no evidence of ulnar entrapment in the right elbow and the nerve conduction study of the right lower extremity was normal. On examination in January 2011, the Veteran complained of intermittent numbness and tingling in the fingers and palm of the right hand which occurred about every other day and lasted a few minutes and some feeling of pins and needles but no burning or pain in his right upper extremity. He complained of intermittent numbness and tingling in the toes of both feet which occurred every other day and lasted a few minutes. He denied any loss of sensation in the lower extremities. Physical examination of the right upper extremity showed intact strength, no muscle weakness or atrophy, normal grip and fine motor control of fingers, an ability to touch the fingertips to the thumb, intact sensation, and absent deep tendon reflexes. Physical examination of the lower extremities showed no muscle weakness or atrophy of the left lower extremity, weakness at 4/5 on hip flexion and knee flexion and extension of the right lower extremity, no muscle atrophy, intact sensation, and deep tendon reflexes were 1 in the patella and 2 in the Achilles. The examiner opined that the Veteran did not have any peripheral neuropathy in any of his four extremities. The diagnoses included peripheral neuropathy not found in the right upper extremity and bilateral lower extremities. The Veteran's service personnel records and service treatment records show that he had in-country duty in Vietnam. He is presumed to have been exposed to herbicide agents during active service. See 38 C.F.R. §§ 3.307, 3.309. Although the Veteran's in-service herbicide exposure is presumed, and peripheral neuropathy is among the diseases for which service connection is available on a presumptive basis, the competent evidence does not show that peripheral neuropathy manifested to a compensable degree within one year of separation from active service. Service connection on a presumptive basis is not warranted. In addition, the Veteran is not entitled to service connection on a direct or secondary basis for peripheral neuropathy of the right upper extremity and peripheral neuropathy of the bilateral lower extremities. In this respect, the most probative evidence does not reflect any diagnosis of peripheral neuropathy within the appeal period or in close proximity to the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007); see Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). In September 2006, the VA examiner found that the Veteran's subjective complaint of pain of the right lower extremity was not consistent with a complication of diabetes mellitus and pre-dated the diagnosis of diabetes mellitus by 18 months. The examiner offered a diagnosis of no peripheral neuropathy found in the Veteran's right upper extremity and bilateral lower extremities. The January 2011 VA examiner confirmed that there was no diagnosis of peripheral neuropathy in any of these extremities. The Board assigns great probative value to the VA examinations because the examiners noted the Veteran's reported symptoms, examined the Veteran, and determined that the Veteran did not have peripheral neuropathy in any of his extremities. The Board acknowledges that the Veteran is competent to provide statements related to his symptoms. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), a diagnosis of peripheral neuropathy falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran has not been shown to have the requisite medical knowledge or expertise to diagnose himself with peripheral neuropathy. As such, his statements do not serve to show that he has a current disability of peripheral neuropathy. In the absence of proof of present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). As the most probative and competent evidence does not reflect a current disability, service connection on a direct and secondary basis is denied for peripheral neuropathy of the bilateral lower extremities and peripheral neuropathy of the right upper extremity. The preponderance of the evidence is against the claims. The benefit-of-the-doubt doctrine is not for application and the claims must be denied. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board acknowledges that, following VA outpatient treatment in October 2007, the Veteran was diagnosed as having ulnar neuropathy after complaining of subjective pain in the right forearm. A subsequent VA EMG in December 2007 showed no ulnar entrapment in the right elbow. Although the Veteran experienced ulnar neuropathy of the right upper extremity during the pendency of this appeal, there is no competent evidence relating such a diagnosis to active service or to his service-connected diabetes mellitus. The September 2006 examiner, while not diagnosing ulnar neuropathy, addressed the Veteran's reported symptoms and found them not to be consistent with diabetes mellitus. There is no competent evidence to suggest otherwise. Again, the Veteran is not competent to opine as to a diagnosis or to the etiology of such a diagnosis. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Ulnar neuropathy falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Further, the service treatment records are absent for any manifestations related to neuropathy. With respect to continuity of symptomatology, ulnar neuropathy is not recognized as a chronic condition under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Even so, the evidence does not support a finding of continuity of symptomatology since service. In fact, a November 1973 examiner indicated that the extremities were unremarkable. Examination of the extremities at that time did not reveal any limitation of motion. There was no muscle weakness or atrophy and no sensory deficit could be demonstrated. The Board does not find it reasonable that the Veteran would experience chronic symptoms and not mention any when examined in 1973. Thus, the Board finds that the Veteran is not credible with respect to any reports of continuity of symptomatology since service. See generally Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (Board can consider bias in lay evidence, conflicting statements of the Veteran, and the significant time delay between the affiants' observations and the date on which the statements were written in weighing credibility). Accordingly, secondary and direct service connection is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application and the claim must be denied. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Right Knee The Veteran contended that he incurred a right knee disability during active service when he was thrown from a tank. He alternatively contended that his service-connected diabetes mellitus caused or aggravated his current right knee disability. The Veteran's separation report of medical examination shows that his lower extremities were clinically evaluated as normal. The records do not show complaints of or treatment for the right knee at any time during active service. As noted above, the Veteran's service personnel records indicate that he had combat service in Vietnam and participated in several combat campaigns as a rifleman. The Veteran testified credibly before the Board in June 2009 that he injured his right knee when he fell during combat in Vietnam. Given the foregoing, the Board finds that the Veteran's reported in-service right knee injury is consistent with the facts and circumstances of his active combat service in Vietnam and persuasively suggest that he injured his right knee during this period of service. See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Although 38 U.S.C.A. § 1154(b) relaxes the evidentiary standard for establishing that a disease or injury was incurred during combat service, it does not create a presumption of service connection for any disease or injury. The Board has conceded in this case that the Veteran incurred an in-service injury to the right knee. However, in order to establish service connection, competent evidence is required to relate the current right knee disability to active service. In a September 2004 VA treatment record, the Veteran was assessed with patellofemoral pain syndrome of the right knee. In February 2005, the Veteran complained of persistent right knee pain. In March 2005, the Veteran complained of right knee pain which had lasted for 2-3 years. He also reported that he had fallen off of a vehicle while in Vietnam and had been treated conservatively. His right knee pain had begun 2-3 years earlier. X-rays showed a normal knee. The assessment was early degenerative joint disease. VA magnetic resonance imaging (MRI) scan of the Veteran's right knee taken in July 2005 showed osteoarthritic changes in both compartments of the knee joint, severe degenerative changes in both menisci, an oblique tear in the posterior horn of the meniscus, a questionable oblique tear in the posterior horn of the lateral meniscus, a small joint effusion, and intact ligamentous structures. On June 9, 2006, the Veteran complained of daily right knee pain over the past number of weeks. On June 26, 2006, the Veteran complained that it felt like his right knee gave out on him. He stated that his right knee had bothered him since an accident in Vietnam in 1968 when he was injured by shrapnel. In a February 2009 letter, the Veteran's VA treating physician stated that the Veteran's history was significant for osteoarthritic changes in both compartments of the right knee joint and severe degenerative changes in both menisci. The Veteran had a history of an oblique tear in the posterior horn of the meniscus previously documented on an MRI of the right knee joint in 2005. In October 2010, the Veteran complained of constant right knee pain since Vietnam. On examination in January 2011, the Veteran's complaints included chronic and daily severe right knee pain in the past few years. The examiner reviewed the Veteran's claims file. This examiner noted that there was no evidence of a right knee injury in the Veteran's service treatment records and no mention of any right knee pain until around 2004. The Veteran reported injuring his right knee in Vietnam but not experiencing any right knee pain until 2-3 years prior to the VA examination. X-rays of the right knee showed no acute fracture or dislocation, no evidence of knee joint effusion, no sclerotic or lytic bony lesion, narrowing of the medial knee joint compartment, and no radiopaque foreign body. The radiologist's impression was narrowing of the medial knee joint compartment. The examiner opined that there was insufficient evidence in the claims file to support the Veteran's claim that his right knee disability was related to active service. The examiner's rationale was that, although the Veteran claimed a shrapnel injury to the right knee, he did not require any special surgery so the injury most likely was superficial. There was no evidence of retained shrapnel fragments on x-ray or MRI scan. Even if the Veteran had sustained a right knee injury during active service, the VA examiner stated that it was too superficial to cause the current severe right knee disability. The examiner concluded that the Veteran's current osteoarthritis of the right knee was less likely than not caused by any in-service injury. This examiner also opined that he could not see how the Veteran's diabetes mellitus "in any way could cause" his current right knee osteoarthritis. The examiner concluded that the Veteran's current right knee disability was not related to his service-connected diabetes mellitus. The diagnosis was osteoarthritis in the right knee with severe degenerative changes and tears in both menisci by MRI. In light of the above, the Board finds that the most probative evidence is against finding that a current right knee disability is related to active service. The Board assigns great probative value to the January 2011 VA examiner's opinion. The examiner reviewed the claims file, considered the Veteran's assertions and noted that even if the Veteran had a right knee injury, it was too superficial to cause the current severe right knee disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion). With respect to the Veteran's statements related to etiology, the Veteran is not competent to provide an opinion as to the etiology of a right knee disability diagnosed, in part, as arthritis. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). He has not been shown to possess the medical knowledge or expertise to provide such an opinion. Therefore, service connection on a direct basis is not warranted. The Board acknowledges the Veteran's assertions and testimony that he incurred a right knee disability during active service and continued to experience symptoms since separation from service. Regardless of any in-service injury, the evidence does not support the Veteran's assertions of continued right knee symptomatology since separation from service. There were no complaints of or treatment for a right knee disability between the Veteran's separation from service in March 1969 and when he first complained of right knee pain in September 2004, decades later. See Maxson, 230 F.3d at 1333. Further, the Veteran has provided inconsistent accounts as to the onset of his symptoms. In March 2005, he reported that he experienced right knee pain for 2-3 years. In January 2006, he reported that he experienced pain in his lower extremities since the weekend before this outpatient visit. On June 9, 2006, the Veteran reported experiencing a few weeks of right knee pain. On examination in September 2006, the Veteran stated that he had experienced pain in his extremities for 5 years. In October 2010, the Veteran reported right knee problems since Vietnam. On examination in January 2011, he reported that he injured his right knee in Vietnam and had not experienced any right knee pain until 2-3 years prior to this examination. Due to the inconsistences, the Board does not find the Veteran to be credible as to his reports of continuity of symptoms since active service. See Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). Therefore, service connection based on continuity of symptomatology is not warranted. Service connection is also not warranted on a secondary basis. The competent evidence does not support the Veteran's assertion that his service-connected diabetes mellitus caused or aggravated his current right knee disability. See 38 C.F.R. § 3.310. The evidence suggests that any right knee injury which occurred during the Veteran's service resolved with in-service treatment, as his right knee was normal at separation. The January 2011 examiner determined that diabetes could not "in any way" cause the Veteran's current severe right knee disability. There is no competent contrary opinion of record. The Veteran is not considered competent to address any relationship between his diabetes mellitus and his right knee disability as this is a complex medical question. See Kahana, id.; Jandreau, id. In light of the above, the Board finds that service connection for a right knee disability, including as due to service-connected diabetes mellitus, is not warranted. The preponderance of the evidence is against the claim. There is no doubt to be resolved and service connection is denied. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Finally, service connection is not warranted on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309. Arthritis is listed among the disease and injuries for which service connection is available on a presumptive basis as a chronic disease, it is not listed among the diseases for which service connection is available on a presumptive basis as a result of in-service herbicide exposure. Id. The Veteran was not diagnosed as having degenerative joint disease of the right knee (or arthritis) until March 2005. Service connection on a presumptive basis is not warranted. ORDER Entitlement to service connection for peripheral neuropathy of the right upper extremity, including as due to herbicide exposure or service-connected diabetes mellitus, is denied. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, including as due to herbicide exposure or service-connected diabetes mellitus, is denied. Entitlement to service connection for a right knee disability, including as due to herbicide exposure or service-connected diabetes mellitus, is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs