Citation Nr: 1538558 Decision Date: 09/09/15 Archive Date: 09/18/15 DOCKET NO. 11-03 666 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a right knee disorder, to include as secondary to a left knee disorder. 2. Entitlement to service connection for a low back disorder, to include as secondary to a left knee disorder. 3. Entitlement to service connection for hypertension, to include as secondary to posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Thomas D. Jones, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from July 1978 to July 1997, at which time he retired from military service. He had service in the Southwest Asia theater of operations from December 1990 until May 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA) in Waco, Texas. This appeal was previously presented to the Board in March 2014 and again in September 2014; on each occasion, these issues were remanded for additional development. The required development has been completed and this case is appropriately before the Board. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. A current right knee disability did not manifest during service or to a compensable degree within a year thereafter, has not been continuous since service separation, was not caused by any in-service disease, injury, or event during service, and is not due to or aggravated by a service-connected disability. 2. A current low back disability did not manifest during service or to a compensable degree within a year thereafter, has not been continuous since service separation, was not caused by any in-service disease, injury, or event during service, and is not due to or aggravated by a service-connected disability. 3. Hypertension did not manifest during service or to a compensable degree within a year thereafter, has not been continuous since service separation, was not caused by any in-service disease, injury, or event during service, and is not due to or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for the award of service connection for a right knee disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2015). 2. The criteria for the award of service connection for a low back disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2015). 3. The criteria for the award of service connection for hypertension have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. 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, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between a Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Upon receipt of the Veteran's claims, VA issued VCAA notice to him in the form of November 2008, January 2009, and August 2009 letters which informed him of the evidence generally needed to support the claims on appeal. This notice included information regarding the assignment of an increased evaluation and effective date; what actions he needed to undertake; and how VA would assist him in developing his claims. The initial VCAA notice letters were also issued to the Veteran prior to the rating decision from which the instant appeal arises; therefore, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Regarding the duty to assist in this case, VA has secured or attempted to secure all relevant documentation required by the VCAA or identified by the Veteran. The Veteran's service treatment records, VA medical records, and any identified private medical records have all been obtained. The Veteran was afforded several VA medical examinations for the disabilities on appeal, most recently in May 2014. The VA and private medical evidence contains sufficiently specific clinical findings and informed discussion of the pertinent history and clinical features of the disabilities on appeal and is adequate for purposes of this appeal, as it is competent medical evidence pertaining to the existence and etiology of the claimed current disabilities sufficient to decide the claim. The Board is not aware of, and the Veteran has not suggested the existence of, any additional pertinent evidence not yet received. All identified and available relevant documentation has been secured and all relevant facts have been developed. There remains no issue as to the substantial completeness of the claims. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). For these reasons, the Board finds that the VCAA duties to notify and to assist have been met. II. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2015); 38 C.F.R. § 3.303(a) (2015). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Service connection may also be established on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117 (West 2014); 38 C.F.R. § 3.317(a)(1). A Persian Gulf veteran is one who served in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2) . In this case, the Veteran's service personnel records confirm his service during the Persian Gulf War in the Southwest Asia Theater of operations. Accordingly, the Board finds the Veteran is a Persian Gulf veteran and the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 may apply if the Veteran is found to have a qualifying chronic disability. The term "qualifying chronic disability" means a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome; fibromyalgia, or functional gastrointestinal disorders (including, but not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia). 38 C.F.R. § 3.317(a)(2)(i). For purposes of this presumption, the term "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). VA regulations clarify that "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Additionally, disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Signs or symptoms which may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, fatigue, signs or symptoms involving skin, headaches, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b). In claims based on undiagnosed illness, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Laypersons, such as the Veteran, are competent to report objective signs of illness such as pain or fatigue. Id at 9-10. To determine whether a qualifying chronic disability is manifested to a degree of 10 percent or more, the rating criteria set forth in the VA Schedule for Rating Disabilities shall be utilized. See 38 C.F.R. § 3.317(a)(5); 38 C.F.R. Part 4 (2014). Even where service connection cannot be presumed, service connection may still be established on a direct basis. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Finally, service connection may be awarded for any disability which is proximately due to or the result of, or is otherwise aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. As with any claim, when there is an approximate balance of positive and negative evidence regarding any matter material to the claim, the claimant shall be given the benefit of the doubt. 38 U.S.C.A. § 5107. a. Right knee The Veteran seeks service connection for a right knee disability, which he claims has been caused or aggravated by a service connection disability, post-operative residuals of a cruciate ligament tear of the left knee. VA is bound to consider all pertinent theories of service connection, whether or not a theory is raised by a veteran. See Schroeder v. West, 212 F.3d 1265 (Fed. Cir. 2000) (holding that a claim for disability compensation should be broadly construed to encompass all possible theories of entitlement). Thus, as an initial matter, the Board must consider service connection on a primary basis, regardless of the Veteran's assertions regarding his claim. The record establishes that the Veteran has a current diagnosis of right knee degenerative joint disease. See the May 2014 VA examination. Thus, the current disability requirement for service connection is satisfied. The Board also notes that because the Veteran has a diagnosis, 38 C.F.R. § 3.317(a)(1), for compensation for certain disabilities occurring in Persian Gulf veterans, is not for application in this case. In the present case, the service treatment records are negative for any diagnosis of or treatment for a right knee disability. The Veteran was afforded a service separation examination in April 1997. At that time, no abnormalities of the right knee were noted. On his April 1997 report of medical history, the Veteran denied any history of a "trick" or locked knee. The first diagnosis of a right knee disability dates to several years after service, and no competent evidence of in-service onset of a chronic right knee disability incurred either during service or within a year thereafter has been presented. Moreover, the Veteran did not initially claim in-service onset of a current right knee disability. On the August 2008 application for compensation, the Veteran reported October 2000, several years after service, as the date of onset of his right knee disability. Thus, the Board finds the preponderance of the evidence to be against the award of service connection on a direct basis for a right knee disability. Regarding the Veteran's claim of service connection for a right knee disability as secondary to a left knee disability, the Board finds the preponderance of the evidence to be against such an award. The Veteran was afforded a VA orthopedic examination in May 2014. The virtual claims file was reviewed by the examiner in conjunction with the examination. The Veteran reported onset of right knee pain during service in 1995-96, but he denied seeking medical treatment for the pain at that time. He did not seek medical treatment for the right knee for several years following service, according to his account. The Board notes that on a prior September 2009 VA examination, the Veteran reported onset of right knee pain in 1997, after service separation. Upon physical examination of the Veteran, the examiner diagnosed mild chronic right knee degenerative joint disease. The examiner opined that it was less likely than not this disorder was incurred during service or was related to a disease or injury during service, as the Veteran did not seek treatment of the right knee during service or for several years thereafter, until 2000. This lengthy period without complaint or treatment is evidence that there has not been ongoing symptomatology, and weighs heavily against the claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Likewise, the examiner opined that the Veteran's service-connected left knee disorder did not cause or aggravate the right knee disorder. The examiner found no evidence in the medical literature of a causal relationship of contralateral knee joint conditions, as there is no direct anatomical association, and no evidence was found of aggravation beyond the normal progression of chronic right knee degenerative joint disease specifically due to left knee condition. Rather, the right knee degenerative joint disease was the result of the natural aging process, in the opinion of the examiner. Based on this competent medical evidence, and in light of the lack of contrary evidence of record, the Board must conclude that while the Veteran has a current diagnosis of a right knee disability, this disability was not either caused or aggravated by a service-connected disability. Thus, service connection on a secondary basis for a right knee disability must be denied. The Veteran has himself asserted that his current degenerative joint disease of the right knee had its onset in service, or within a year thereafter, or is due to or results from a service-connected disability. He has also submitted several lay statements in support of his claim. A layperson is competent to report observable symptomatology which comes to him via his senses. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some medical issues, however, require specialized training for a determination as to diagnosis and causation, and such issues are therefore not susceptible of lay opinions on etiology, and the Veteran's statements therein cannot be accepted as competent medical evidence. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). Lay testimony on the etiology of current diagnoses of degenerative joint disease is not competent in the present case, because the Veteran is not competent to state that this disability had its onset in service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011) (lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent). An opinion of etiology would require knowledge of the complexities of the orthopedic system and the various causes of degenerative joint disease, knowledge that the Veteran is not shown to possess. While the Veteran is competent to report such observable symptomatology as joint pain, diagnoses such as degenerative joint disease are based on X-rays and other objective clinical findings, and are not conducive solely to lay observation. The Veteran has also not alleged that he was told of such a nexus by a competent expert, and such assertions have not subsequently been verified by such an expert. The Board further notes that the Veteran's assertions are of questionable credibility, as he has given various dates of onset regarding his right knee pain. He has stated both that such pain began during service, and later, after service. The Board again notes that on service separation examination in 1997, he denied any history of right knee pain, and no abnormality of the right knee was noted on objective examination. He also reported, in his initial VA compensation claim, onset of right knee pain in October 2000. Likewise, the lay statements submitted by the Veteran's friends and family are of limited probative value. These statements only confirm his current reports of recurrent right knee pain, but do not provide competent evidence of either an in-service disease or injury of the right knee, or a nexus to a service-connected disability. As these statements are all from laypersons, they are not probative regarding the etiology of the Veteran's degenerative joint disease of the right knee, for the reasons already stated. See Jandreau, 492 F.3d at 1372. For the reasons and bases discussed above, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for a right knee disability, including as a presumptive disease, on both a direct and secondary basis, and this claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. b. Low back The Veteran seeks service connection for a low back disability. He has asserted both that a low back disability was incurred in service, and that such a disability was caused or aggravated by a service-connected disability. The record establishes that the Veteran has a current diagnosis of myofascial strain. See May 2014 VA examination. Thus, the current disability requirement for service connection is satisfied. The Board also notes that because the Veteran has a diagnosis, 38 C.F.R. § 3.317(a)(1), for compensation for certain disabilities occurring in Persian Gulf veterans, is not for application in this case. The Veteran was without a low back disability when he was examined and accepted for service in 1979. He sought treatment for low back pain in September 1980, at which time he reported pain of one month's duration. No specific injury was reported, however. On objective evaluation, he was without swelling or deformity, but pain was noted with motion. Range of motion was otherwise excellent. The assessment was of possible back spasms or strained low back muscles. He was put on rest and told to apply heat to his back. In November 1980, the Veteran sought again treatment for low back pain on the right side. On physical evaluation, he had full range of motion and moderate pain to touch. The diagnosis was of a bruised or strained back muscle and he was given medication and rest. He did not seek further treatment of his low back during service, according to the service treatment records. The Veteran was afforded a service separation examination in April 1997. At that time, no abnormalities of the spine or low back were noted. On his April 1997 report of medical history, the Veteran denied any history of recurrent back pain or a back injury of any sort. Thus, based on the lack of evidence of a low back disability at service separation, the Board must conclude that any in-service disease or injury of the low back was acute and transitory in nature, as it was not present at service separation. The Board next finds that a chronic disability of the low back did not manifest to a compensable degree within a year of service separation. On VA orthopedic examination post-service in September 2009, the Veteran reported onset of low back pain in 2000, several years after service separation. On the initial August 2008 claim for VA compensation, he reported onset of a low back disability in June 1999, several years after service. Thus, by the Veteran's own admission at that time, he did not experience symptoms of a low back disability at service separation and for several years thereafter. Likewise, the competent evidence of record is against a finding either of onset of a low back disability during service or as otherwise related to any disease, injury, or incident therein. The Veteran was afforded a VA orthopedic examination in May 2014. The virtual claims file was reviewed by the examiner in conjunction with the examination. He stated he first began experiencing low back pain in service in approximately 1996, but did not go to sick call at that time. He did seek medical treatment for the low back pain from a civilian provider in about 1999, and eventually began pain medication with VA treatment in about 2000. On review of the record, the examiner noted the Veteran sought treatment for low back pain during service, but reported resolution of his symptoms at service separation. Following service, the Veteran was involved in a motor vehicle accident in 2006, after which he reported back pain. After physical examination of the Veteran, the examiner diagnosed a chronic thoracolumbar spine myofascial strain. Regarding the onset of the Veteran's low back disorder, the VA examiner concluded there was no evidence found for treatment of a chronic low back pain/strain during military service, and Veteran had normal examination findings on the retirement physical examination in 1997. Therefore, the examiner concluded the episodes of low back strain during military service were acute in nature and resolved during service. The Veteran by history had further back pain following a motor vehicle accident several years after military service, which was treated. No further record was found for back treatment until 2009. The examiner also opined that it was less likely than not the low back disability was caused by the service-connected left knee disability. The examiner noted the medical literature did not indicate a causal relationship of lumbar spine myofascial strains to knee joint dysfunctions, as there is no direct anatomical association. Likewise, the examiner concluded there was no evidence found of aggravation beyond the normal progression of the chronic lumbar spine strain specifically due to the left knee condition. Based on this competent medical evidence, and in light of the lack of contrary evidence of record, the Board must conclude that while the Veteran has a current diagnosis of a low back disability, this disability was not incurred in service, did not manifest to a compensable degree within a year of service separation, and was not either caused or aggravated by a service-connected disability. Thus, service connection on both a direct and secondary basis for a low back disability must be denied. The Veteran has himself asserted that his current low back disorder had its onset in service, or within a year thereafter, or is due to or results from a service-connected disability. A layperson is competent to report observable symptomatology which comes to him via his senses. See Jandreau, 492 F.3d at 1372. Some medical issues, however, require specialized training for a determination as to diagnosis and causation, and such issues are therefore not susceptible of lay opinions on etiology, and the Veteran's statements therein cannot be accepted as competent medical evidence. See Clemons, 23 Vet. App. at 6. Lay testimony on the etiology of current diagnoses of orthopedic disorders are not competent in the present case, because the Veteran is not competent to state that any such disability had its onset in service. See Davidson, 581 F.3d at 1316. An opinion of etiology would require knowledge of the complexities of the orthopedic system and the various causes of spinal disease, knowledge that the Veteran is not shown to possess. While the Veteran is competent to report such observable symptomatology as back pain, diagnoses such as a spinal strain are based on X-rays and other objective clinical findings, and are not conducive solely to lay observation. The Veteran has also not alleged that he was told of such a nexus by a competent expert, and such assertions have not subsequently been verified by such an expert. The Board further notes that the Veteran's assertions are of questionable credibility, as he has given various dates of onset regarding his back pain. He has stated both that such pain began during service, and later, after service. The Board again notes that on service separation examination in 1997, he denied any history of recurrent back pain, and no abnormality of the low back was noted on objective examination. On the initial August 2008 claim, he reported onset of a low back disability in 1999, several years after service separation. Likewise, the lay statements submitted by the Veteran's friends and family are of limited probative value. These statements only confirm his current reports of recurrent low back pain, but do not provide competent evidence of either an in-service disease or injury of the low back, or a nexus to service or a service-connected disability. As these statements are all from laypersons, they are not probative regarding the etiology of the Veteran's strain of the thoracolumbar spine, for the reasons already stated. See Jandreau, 492 F.3d at 1372. For the reasons and bases discussed above, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for a low back disability, including as a presumptive disease, on both a direct and secondary basis, and this claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. c. Hypertension The Veteran seeks service connection for hypertension. He asserts this disorder had its onset during active duty service, or as the result of a service-connected disability. For VA purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Concerning the question of in-service disease or injury, service treatment records do not reflect a diagnosis of or treatment for hypertension or high blood pressure readings. The Veteran was afforded a service separation examination in April 1997. At that time, his blood pressure was 138/76. Hypertension was not diagnosed. On his April 1997 report of medical history, the Veteran denied any history of high or low blood pressure. Thus, blood pressure readings during service and at service separation do not meet VA's definition of hypertension, and a diagnosis of hypertension was not provided by any medical examiner at that time. The Board finds that hypertension did not manifest to a compensable (10 percent) degree within a year of service separation. On VA examination in September 2009, the Veteran reported hypertension was first diagnosed in 2000, several years after service separation. Private treatment records dated in 2008 confirm a diagnosis of and medication use for hypertension. The Veteran has more recently alleged that he was diagnosed by a private physician with hypertension within a year of his service separation; he has not, however, presented his private treatment records or any other evidence to verify this account. As these statements contradict both the evidence of record and the Veteran's own prior statements, they are not considered credible by the Board. Thus, the Board concludes the Veteran's hypertension did not manifest to a compensable degree within a year of service separation. Likewise, the competent evidence of record is against a finding that the Veteran's hypertension is caused or aggravated by a service-connected disability. The Veteran was afforded a VA hypertension examination in May 2014. The virtual claims file was reviewed by the examiner in conjunction with the examination. The examiner noted that the Veteran had a current diagnosis of hypertension, and was on daily medication for control of the same. The Veteran reported that he was first diagnosed with hypertension by a private physician in 1997 shortly after service separation. He was initially prescribed medication at that time. Upon examination of the Veteran and review of the record, the VA examiner opined it was less likely than not the Veteran's hypertension was either caused or aggravated by a service-connected disability, to include posttraumatic stress disorder (PTSD). The examiner noted that PTSD was not diagnosed until 2009, and hypertension had been diagnosed in approximately 2000, several years prior. Additionally, the examiner found no evidence that the Veteran's hypertension was permanently worsened beyond the natural progression of the disorder by PTSD; while the Veteran's blood pressure readings have shown some fluctuation, his hypertension was generally under control due to his medication use. Thus, based on the above, the Board finds the preponderance of the evidence to be against the conclusion the Veteran's hypertension began during service, or otherwise had its onset therein, or within a year of service separation. The Board also finds the preponderance of the evidence to be against a finding that hypertension was either caused or aggravated by a service-connected disability. The competent evidence of record suggests against such a nexus, and the Veteran has submitted no competent evidence in support of this contention. The Veteran has himself asserted that his hypertension began in service, or as secondary to his PTSD. A layperson is competent to report observable symptomatology which comes to him via his senses. See Jandreau, 492 F.3d at 1372; see also Buchanan, 451 F.3d at 1331. Some medical issues, however, require specialized training for a determination as to diagnosis and causation, and such issues are therefore not susceptible of lay opinions on etiology, and the Veteran's statements therein cannot be accepted as competent medical evidence. See Clemons, 23 Vet. App. at 6 ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert, 21 Vet. App. at 462 (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). Lay testimony on the etiology of a current diagnosis of hypertension is not competent in the present case, because the Veteran is not competent to state that hypertension has resulted from pyridostigmine bromide use or as secondary to PTSD. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011) (lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent). An opinion of etiology would require knowledge of the complexities of the cardiovascular system and the various causes of hypertension, knowledge that the Veteran is not shown to possess. The Veteran has also not alleged that he was told of such a nexus by a competent expert, and such assertions have not subsequently been verified by such an expert. For the reasons and bases discussed above, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for hypertension, including as a presumptive disease, as due to an in-service disease or injury, or as secondary to service-connected PTSD, and this claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for a right knee disability is denied. Service connection for a low back disability is denied. Service connection for hypertension is denied. ____________________________________________ H. SEESEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs