Citation Nr: 1601245 Decision Date: 01/12/16 Archive Date: 01/21/16 DOCKET NO. 02-15 984 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for a left knee disorder, to include by way of aggravation. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Hannan, Counsel INTRODUCTION The appellant enlisted in the Army National Guard in July 1982, and he was a member until August 1991. While a member of the Army National Guard, he had various periods of active duty training (ACDUTRA) and inactive duty training (INACDUTRA), including one initial period of ACDUTRA in the Army from September 27, 1982 to February 15, 1983, and one day of INACDUTRA on December 29, 1990. This case originally came before the Board of Veterans' Appeals (Board) on appeal from a March 2002 rating decision issued by the Little Rock, Arkansas, Regional Office (RO) of the Department of Veterans Affairs (VA) that, in part, denied the appellant's claim of entitlement to service connection for a left knee disorder. In November 2004, a Travel Board hearing was held at the RO before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the claims file. Thereafter, the Board denied the left knee service connection claim in a decision issued in June 2005. The appellant then appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court) and, in a decision dated in January 2008, the Court, in pertinent part, vacated the Board's decision and remanded the case. In an August 2008 decision, the Board again denied the appellant's claim for service connection. The appellant appealed that decision to the Court. In a November 2009 decision, the Court affirmed the Board's August 2008 decision. The appellant then appealed the Court's decision to the United States Court of Appeals for the Federal Circuit (Federal Circuit). In a June 2010 decision, the Federal Circuit Court stated that the issue on appeal was limited to entitlement to service connection for a left knee disorder. The Federal Circuit Court affirmed the Court's November 2009 decision in part, vacated in part, and remanded the case to the Court. In a November 2010 memorandum decision, the Court vacated the Board's August 2008 decision with respect to the appellant's claim for service connection for a left knee disorder, and remanded the matter to the Board. Thereafter, the Board denied entitlement to service connection for a left knee disorder in an August 2011 decision. The appellant then appealed the decision to the Court. In November 2012, VA's General Counsel filed a unilateral motion for vacatur and remand because one of the two volumes that comprised the appellant's claims file was lost in transit in August 2012. In January 2013, the Court granted the motion and remanded the case to the Board. Because VA could not produce the complete record considered by the Board when it issued the August 2011 decision, the case had to be remanded to allow the RO to reconstruct the appellant's claims file and to produce a new decision based on the reconstructed file. See 38 U.S.C.A. § 7252(b) ("Review in the Court shall be on the record of proceedings before the Secretary and the Board."). Pursuant to the August 2013 Board remand directives, the RO reconstructed the claims file and then issued a decision based on the current record. The Board subsequently remanded the case for additional development in June 2014; the case has now been returned to the Board for appellate review. In July 2015, the Board requested a medical expert opinion pursuant to 38 U.S.C.A. § 5107(a) and 38 C.F.R. § 20.901. A medical opinion from an orthopedic surgeon who specializes in knee reconstruction was rendered in July 2015. VA duly gave notice to the appellant and his representative; responses were received from both the appellant and his representative in December 2015. The appellant submitted additional evidence to the Board in December 2015; this evidence consisted of copies of private medical records dated between 2002 and 2011. The Board cannot consider additional pertinent evidence without first remanding the case to the agency of original jurisdiction (AOJ) for initial consideration or without first obtaining the appellant's waiver. 38 C.F.R. § 20.1304. However, in December 2015, the appellant also submitted a written waiver of review of the newly submitted evidence by the AOJ. Therefore, referral to the AOJ is not required. See 38 C.F.R. § 20.1304. This appeal was processed using the VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into account the existence of this electronic record. FINDINGS OF FACT 1. The appellant underwent left knee surgery at age twelve and radiographic examination in July 1982, prior to his entry into the National Guard, revealed considerable spurring of the articular margin of the lateral femoral condyle of both medial and lateral aspects, some irregularity of the articular surface of the lateral tibial plateau and irregularity of the lateral medial condyle; physical examination revealed crepitation on movement of the left knee. 2. While working at his civilian occupation as a truck driver on December 27, 1990, the appellant injured his cervical spine, lumbar spine, left knee and left ankle in a motor vehicle accident (MVA). 4. The appellant was on INACDUTRA on December 29, 1990. 5. Based on the evidence of record, it is not shown that the appellant has any left knee disorder, including arthritis, that was acquired during any period of ACDUTRA or INACDUTRA, and it is not shown that there was a permanent worsening of any underlying left knee condition based on any occurrence or event during any period of ACDUTRA or INACDUTRA. CONCLUSION OF LAW The appellant's pre-existing left knee disorder was not aggravated during any period of ACDUTRA or INACDUTRA. 38 U.S.C.A. §§ 101, 106, 1101, 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.1, 3.6, 3.102, 3.303, 3.306 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION In adjudicating a claim, the Board determines whether (1) the weight of the evidence supports the claim or, (2) whether the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim. The appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The appellant is seeking service connection for a left knee disorder; he is not currently service-connected for any medical or psychiatric condition or disorder. The appellant testified at his April 2003 personal hearing at the RO that he felt pain in his left knee on December 29, 1990, related to his carrying his heavy duffle bags when reporting for National Guard duty. See RO Hearing Transcript p. 1. The appellant testified that he was seen in the Troop Medical Clinic on January 24, 1991, where he was given a profile based on neck, lower back, left knee and left ankle injuries, as well as left leg muscle spasms; he said that he was using a wheelchair at that time. See RO Hearing Transcript pp. 1-2. The appellant provided similar testimony at his November 2004 Travel Board hearing. He also stated that his National Guard duty on December 29, 1990, was inactive duty training. See Board Hearing Transcript p. 3. The appellant testified that he had been in an accident on December 27, 1990, and that he sustained elevated pain in the areas injured in the accident, including the left knee, due to lifting and carrying military equipment such as duffle bags, chairs, food service equipment, radio equipment and other equipment on December 29, 1990, while on INACDUTRA. He contended that his case warranted service connection because the pre-existing left knee problems he had from the December 1990 MVA were aggravated and taken to another level. The appellant's representative clarified that the appellant was arguing that the left knee residuals were aggravated due to the events of December 29, 1990. See Board Hearing Transcript pp. 3-4 and p. 8-9. The evidence of record also includes written statements about the events of December 29, 1990. The appellant submitted a statement, in January 2001, in which he declared that while he was gathering his Guard equipment in order to report on that day, he was in severe pain and, as a result, fell in his parking lot. He maintained that the heavy duffle bags affected his injured areas, including his left knee, causing him to collapse and that he subsequently had to carry those heavy bags into the Armory. An August 2001 statement from the appellant's spouse states that she is a registered nurse. She stated that she had notified her husband's captain on December 28, 1990, about the injuries he had suffered the day before. She further stated that she helped her husband to dress, that he would not allow her to carry his heavy bags and that, as they proceeded outdoors to the car, the appellant fell with all that heavy equipment. She said that his pain intensified all over again when they arrived at the Armory and he exited the car. A January 2002 statement from the appellant indicates that he was dressed in his battle dress uniform with a neck brace and a leg brace over them. He said that he had to use one crutch, too. The appellant further stated that he grabbed his bags, proceeded to the car and fell down. He said that after arriving at the Armory, he suffered there in pain for several hours before being sent home. To establish service connection for a disability resulting from a disease or injury incurred in service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases (including arthritis and sensorineural hearing loss) may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term "chronic disease" refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where a chronic disease under 38 C.F.R. § 3.309(a) is "shown as such in service" ("meaning clearly diagnosed beyond legitimate question" Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)), or in the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In cases where a chronic disease is "shown as such in service", a veteran is "relieved of the requirement to show a causal relationship between the condition in service and the condition for which service connected disability compensation is sought." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Instead, service connection may be granted for subsequent manifestations of the same chronic disease without any evidence of link or connection between the chronic disease shown in service and manifestations of the same disease at a later time. In other words, "there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. If evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not "shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned," i.e., "when the fact of chronicity in service is not adequately supported," then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Active military, naval, or air service includes any period of active duty or ACDUTRA during which the individual concerned was disabled from disease or injury incurred in or aggravated in the line of duty, or any period of INACDUTRA during which the individual concerned was disabled from injury (but not disease) incurred in or aggravated in the line of duty. 38 U.S.C.A. §§ 101(21), (22), (23), (24), 106; 38 C.F.R. § 3.6(a), (c), (d). Accordingly, service connection may be granted for disability resulting from disease or injury incurred in or aggravated while performing ACDUTRA or for injury incurred in or aggravated while performing inactive duty for training (INACDUTRA). 38 U.S.C.A. §§ 101(24), 106, 1110, 1131. I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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 in accordance with 38 C.F.R. § 3.159(b)(1). The VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, the RO did provide the appellant with notice in March 2001, December 2001, and March 2002, prior to the initial decision on the claim in March 2002. The appellant was also provided a notification letter in November 2003. The timing requirement of the notice as set forth in Pelegrini has been met in connection with the claim and to decide the appeal would not be prejudicial to the claimant. Moreover, the requirements with respect to the content of the notice were met in this case. The RO informed the appellant in the notice letters about the information and evidence that is necessary to substantiate his claim for service connection. Specifically, the November 2003 letter indicated that the evidence must show that the appellant had an injury in military service or a disease that began in, or was made worse during military service, or that there was an event in service that caused injury or disease; that he has a current physical or mental disability; and, that there is a relationship between his current disability and an injury, disease, or event in military service. Additionally, the September 2002 statement of the case (SOC) and the June 2004 and October 2004 supplemental statements of the case (SSOC) notified the appellant of the reasons for the denial of his application and, in so doing, informed him of the evidence that was needed to substantiate his claim. In addition, the RO notified the appellant in the notice letters about the information and evidence that VA will seek to provide. In particular, the November 2003 letter indicated that reasonable efforts would be made to help him obtain evidence necessary to support his claim, including that that VA was requesting all records held by Federal agencies, such as service medical records, military records, and VA medical records. The appellant was also informed that a medical examination would be provided or that a medical opinion would be obtained if it was determined that such evidence was necessary to make a decision on his claim. The RO also informed the appellant about the information and evidence that he was expected to provide. Specifically, the November 2003 letter notified the appellant that he must provide enough information about his records so that they could be requested from the agency or person that has them. The March 2001, March 2002, and November 2003 letters also requested that he complete and return the enclosed VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs, if there were any private medical records that he would like VA to obtain on his behalf. In addition, the November 2003 letter informed the appellant that it was his responsibility to ensure that VA receives all requested records that are not in the possession of a Federal department or agency Thus, the appellant was provided with notice of what type of information and evidence was needed to substantiate his claim for service connection. However, he was not provided with notice of the type of evidence necessary to establish a disability rating or an effective date. Despite the inadequate notice provided to the appellant on those latter elements, the Board finds no prejudice to the appellant in proceeding with the issuance of a final decision. In that regard, as the Board concludes below that the appellant is not entitled to service connection for a left knee disorder, any question as to the appropriate disability rating or effective date to be assigned is rendered moot. The appellant has had ample opportunity to respond/supplement the record and he has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). The United States Supreme Court has held that an error in VA notice should not be presumed prejudicial, and that the burden of showing harmful error rests with the party raising the issue, to be determined on a case-by-case basis. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). In this case, neither the appellant nor his representative has alleged any prejudicial or harmful error in VA notice, and the Board finds, based the factors discussed above, that no prejudicial or harmful error in VA notice has been demonstrated in this case. As for the duty to assist, the appellant's claims file has been rebuilt and his service medical treatment records have been included in the claims file and reviewed. VA and private medical treatment records have been associated with the claims file and reviewed. A VHA orthopedic surgeon opinion was obtained by the Board in July 2015. To the extent that the rebuilt file does not contain any records that were included in the original claims file, the Board notes that there is no presumption, either in favor of the claimant or against VA, arising from missing records. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) (the Court declined to apply an "adverse presumption" where records have been lost or destroyed while in Government control which would have required VA to disprove a claimant's allegation of injury or disease in service in these particular cases). Moreover, the case law does not lower the legal standard for proving a claim for service connection but rather increases the Board's obligation to evaluate and discuss in its decision all the evidence that may be favorable to the Veteran. Russo v. Brown, 9 Vet. App. 46 (1996). A remand from the Board or from the United States Court of Appeals for Veterans Claims (Court) confers upon a veteran the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In this case, pursuant to the August 2013 and June 2014 Board remands, the appellant's claims file was rebuilt and the private physician who had provided a September 2013 medical opinion was asked to clarify aspects of his opinion. The appellant has notified VA that the private physician has refused to provide clarification without compensation and the appellant has asked that the case be sent to the Board without getting the requested clarification. Therefore, substantial compliance has been achieved. A medical opinion is adequate for claims purposes when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The July 2015 VHA orthopedic opinion was rendered by a medical professional, and the associated report reflects review of the appellant's prior medical records. The opinion included descriptions of the appellant's left knee pathology, contained a review of the appellant's medical history relating to the left knee and demonstrated objective evaluations. The VHA orthopedic surgeon, a specialist in knee reconstruction, was able to assess the nature of the appellant's claimed left knee disorder. The Board finds that the July 2015 VHA orthopedic opinion report is sufficiently detailed with recorded history and clinical findings. In addition, it is not shown the report was in any way incorrectly prepared or that the VHA knee reconstruction expert failed to address the clinical significance of the appellant's claimed left knee pathology. As a result, the Board finds that additional development by way of another opinion or by way of an examination would be redundant and unnecessary. See 38 C.F.R. § 3.326 and 38 C.F.R. § 3.327 and Green v. Derwinski, supra. Therefore, the Board concludes that the appellant was afforded an adequate medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The appellant was provided with notice as to the medical evidence needed for service connection, as well as the assistance VA would provide and he was supplied with the text of 38 C.F.R. § 3.159. Therefore, there is no duty to assist that was unmet and the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the veteran has been prejudiced thereby). Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. The Merits of the Claim There has been no dispute that the appellant's original left knee condition - which resulted in surgery when he was twelve years old - preexisted his active service, and therefore was not incurred during ACDUTRA or INACDUTRA. This childhood condition is clearly documented in the record, and there has been no assertion or any indication that it occurred during any type of military duty. Furthermore, the Board notes that the pre-service July 1982 medical examination specifically indicated that the left knee condition had preexisted the appellant's military service, that the left knee condition had required surgery and that radiographic examination had demonstrated the presence of left knee degenerative changes. Likewise, the appellant admits that he suffered an injury to his left knee as a result of a civilian work-related motor vehicle accident that occurred on December 27, 1990. The medical evidence of record, including that relating to the appellant's receipt of associated Workers Compensation benefits, refers to the existence of the left knee injury after the December 27, 1990 accident. The appellant contends that he incurred an aggravation of the left knee injury as a result of his one day of INACDUTRA on December 27, 1990. Review of the appellant's service medical treatment records reveals that the appellant underwent an enlistment examination in July 1982; he reported that he had undergone left knee surgery for torn cartilage when he was twelve years old. The July 1982 report from an orthopedic consultation indicates that there was a healed surgical scar over the lateral and anterior lateral aspect of the appellant's left knee. There was no synovial thickening. There was some irregularity of the articular margin of the left femoral condyle. There was no instability of the cruciate or collateral ligaments. Extension and flexion of the knee were normal. There was minimal crepitation on movement of the left knee. Radiographic examination revealed considerable spurring of the articular margin of the lateral femoral condyle of both the medial and lateral aspects, as well as some irregularity of the articular surface of the lateral tibial plateau. There was also a slight irregularity of the lateral medical condyle. The orthopedist rendered a diagnosis of residuals of apparent lateral menisectomy of the left knee with mild irregularity of the articular margins without atrophy or synovitis. Reports from the appellant's primary care physician, dated December 28, 1990, indicate that radiographic examination of the left knee had been negative and that physical examination had resulted in a clinical impression of left knee pain. There is no evidence that the appellant received any treatment at the National Guard on December 29, 1990. A February 1991 sick slip indicates that the appellant was still under the care of a doctor for the injuries from the MVA. A letter from the appellant's private primary care physician dictated on March 8, 1991, states that the doctor saw the appellant on March 1, 1991, and that the appellant was diagnosed with headaches, neck pain, lower back pain, ankle pain and muscle spasm in the left leg; there was no mention of any left knee problem. A DA Form 3349, Physical Profile, dated March 10, 1991, states that the appellant was continued on a profile; he was assessed with a PULHES score of 3T for the upper and lower extremities. ('PULHES' profile reflects the overall physical and psychiatric condition of an individual on a scale of 1 (high level of fitness) to a 4 (medical condition or physical defect that is below the level of medical fitness required for retention in the military service). The "P" stands for "physical capacity or stamina," the "U" indicates "upper extremities," the "L" is indicative of "lower extremities," the "H" reflects the condition of the "hearing and ears," the "E" is indicative of the "eyes," and the "S" stands for "psychiatric condition." Odiorne v. Principi, 3 Vet. App. 456 (1992)). An April 24, 1991 letter from the appellant's private orthopedic surgeon states that the appellant's left knee was normal. A DA Form 3349, Physical Profile, dated May 4, 1991, states that the appellant did not meet the physical fitness standards for retention due to a cervical strain; he was assessed with a PULHES score of 4 for the upper extremities and 1 for the lower extremities. An April 1994 private treatment note includes diagnoses of anterior compartment impingement of the left knee with synovitis and plica and recurrent tear of the lateral meniscus. The surgical note indicates that, while the appellant had had a previous lateral menisectomy, there was still meniscus present and a recurrent tear of the lateral meniscus such that the surgeon had to completely remove the offending meniscal material that was causing the inflammation of the posterior and anterior lateral compartment. A February 1997 private treatment report indicates that the appellant presented for treatment in November 1996, and that the doctor had rendered a diagnosis of possible internal derangement of the left knee. The appellant subsequently reported that he had been involved in a minor car wreck in December 1996. The doctor stated that the appellant's symptoms had begun to improve in January 1997, and that, in February 1997, there was some low-grade synovitis of the left knee with evidence of pain on motion. In a June 2001 private treatment report, the physician stated that the appellant had presented for an evaluation of the left knee. The doctor reviewed the appellant's history and noted that he had been diagnosed with a strain of the left knee after the December 27, 1990 MVA, that the appellant had been on active duty in December 1990, and that he presented with current complaints of persistent chronic knee pain. Radiographic examination revealed osteoarthritic changes of the left knee. Records from the beginning of 2002 indicate that the appellant had been diagnosed with internal derangement of the knee. An April 2003 report indicates that the appellant's left knee showed evidence of traumatic arthritis. A March 2011 report indicated that the appellant was still having chronic trouble with his left knee. In May 2011, the appellant told the doctor that he related his problems to the time he was in the Armed forces in 1990, when he fell and injured himself. A September 2013 letter from a private internal medicine physician contains an opinion that the appellant's left knee condition is related to the December 29, 1990 fall described by the appellant because the fall more likely than not broke the remainder of the cartilage in the left knee and necessitated the 1994 knee surgery. The physician stated that he had reviewed what had been represented to him as the totality of the appellant's available medical records. However, the doctor did not mention whether these records he reviewed had included the service medical treatment records or the records relating to the treatment for the left knee injury the appellant incurred on December 27, 1990. In addition, the doctor did not provide a rational for his opinion regarding the left knee. Specifically, the physician did not explain how he determined that it was the fall on December 29, 1990 that broke the rest of the appellant's left knee cartilage as opposed to the injury from the December 27, 1990 MVA; or explain how, in light of the April 24, 1991 letter from the appellant's treating orthopedic surgeon stating that the appellant's left knee was normal, he determined that the appellant's preexisting left knee pathology had been aggravated on December 29, 1990; or explain how he determined that the recurrent lateral meniscus tear observed in April 1994 had occurred on December 29, 1990, versus the development of the tear over time from, for example, lost resiliency in the meniscus or sequelae from the left knee surgery performed when the appellant was twelve years old. A July 2015 VHA medical opinion from an orthopedic surgeon who specializes in knee reconstruction states that the appellant's medical records were reviewed, including the September 2013 private medical opinion. The VHA orthopedic surgeon noted that the private physician was a specialist in internal medicine, pharmacology and toxicology. The VHA specialist noted that the appellant's medical records described a serious injury to the left knee that occurred in childhood with the appearance of degenerative changes that preceded the claimed aggravation by several years. The VHA orthopedic surgeon stated that the appellant's lateral meniscus was not repaired and that it was at least partially removed in childhood which severely inhibited the distribution of contact stress within the lateral compartment of the appellant's knee and within the knee joint itself. The VHA expert noted that the literature clearly and unmistakably demonstrated that this type of injury causes degenerative joint disease (DJD) in the vast majority of individuals. The sequelae of the childhood injury and surgery for the appellant were expected to be symptomatic DJD. The orthopedic surgeon concluded that the appellant's symptoms and need for surgical intervention in 1994 was not at all surprising. The orthopedic surgeon also stated that the recurrent tear of the lateral meniscus described in the April 1994 private operative report would be considered a minor injury in terms of its effect on the joint reactive forces of the knee and that the potential for aggravation was unlikely. In other words, the significant damage in the appellant's left knee occurred in childhood and, once his lateral meniscus was removed, the loss of the normal dissipation of hoop stresses generated within the lateral compartment of the knee was a devastating irreversible injury and further degenerative tearing within the knee, including further meniscus tearing and arthritis, was expected going forward after the initial injury. The VHA orthopedic surgeon opined that the facts that the appellant was involved in an MVA on December 27, 1990, and had a fall on December 29, 1990, did not change the prognosis or natural history of the appellant's knee injury. There was no evidence that either of these two incidents changed the natural history of the appellant's left knee DJD. While the incidents could perhaps reflect temporary short-term exacerbating occurrences, they were not aggravating to any extent. Thus, the VHA orthopedic specialist concluded that it was less than 50 percent likely that the appellant's left knee condition was aggravated to any degree by the fall in 1990 and that the current condition of the left knee was more likely due to the expected sequelae of the injury that occurred when the appellant was twelve years old. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. "The term 'active military, naval, or air service' includes active duty, any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty for training during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty." 38 U.S.C.A. § 101(24). It follows from this that service connection may be granted for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA or injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 1110, 1131; see McManaway v. West, 13 Vet. App. 60, 67 (1999) (quoting Brooks v. Brown, 5 Vet. App. 484, 485 (1993) (discussing 38 U.S.C. §§ 101(24), 1131) (stating that the law "permits service connection for persons on inactive duty [training] only for injuries, not diseases, incurred or aggravated in line of duty"). Certain evidentiary presumptions--such as the presumption of sound condition at entrance to service, the presumption of aggravation during service of preexisting diseases or injuries which undergo an increase in severity during service, and the presumption of service incurrence for certain diseases which manifest themselves to a degree of disability of 10 percent or more within a specified time after separation from service--are provided by law to assist veterans in establishing service connection for a disability or disabilities. 38 U.S.C.A. § 1111, 1112, 1153; 38 C.F.R. § 3.304(b), 3.306, 3.307, 3.309. The advantages of these evidentiary presumptions do not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA. Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying presumptions of sound condition and aggravation to appellant's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period); McManaway, 13 Vet. App. at 67 (citing Paulson, 7 Vet. App. at 469-70, for the proposition that, "if a claim relates to period of [ACDUTRA], a disability must have manifested itself during that period; otherwise, the period does not qualify as active military service and claimant does not achieve veteran status for purposes of that claim" (emphasis in McManaway)); see also Biggins v. Derwinski, 1 Vet. App. 474, 479 (1991) (Steinberg, J., concurring). Thus, the evidentiary burden is on the appellant to show that he became disabled from an injury or disease incurred in line of duty during ACDUTRA or from an injury incurred in the line of duty during INACDUTRA. Any individual who, when authorized or required by competent authority, assumes an obligation to perform ACDUTRA or INACDUTRA, and who is disabled from an injury incurred while proceeding directly to or returning directly from such ACDUTRA or INACDUTRA, shall be deemed to have been on ACDUTRA or INACDUTRA, as the case may be. VA will determine whether such individual was so authorized or required to perform such duty and whether the individual was disabled from injury so incurred. In making such determination, there shall be taken into consideration the hour on which the individual began to proceed or return; the hour on which the individual was scheduled to arrive for or ceased to perform such duty; the method of travel employed; the itinerary; the method in which the travel was performed; and the immediate cause of disability. Whenever any claim is filed alleging that the claimant is entitled to benefits by reason of this subsection, the burden of proof shall be on the claimant. 38 U.S.C.A. § 106(d); 38 C.F.R. § 3.6(e). In accordance with 38 U.S.C.A. § 106, VA has the authority to determine whether the appellant was in active service, including INACDUTRA, at the time a claimed injury occurred. VA regulations governing requirements for establishing service for VA benefits purposes require military service department verification of the appellant's service. See Duro v. Derwinski, 2 Vet. App. 530, 532 (1992); 38 C.F.R. § 3.203. "[O]nly official service department records can establish if and when an individual was serving on active duty, [ACDUTRA], or [INACDUTRA]." Cahall v. Brown, 7 Vet. App. 232, 237 (1994). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. Records received from the Army National Guard establish that the appellant's status on December 29, 1990, was INACDUTRA. The National Guard documents indicate that he was not on active duty at any time between July 11, 1990, and August 7, 1991, and that he had no credible service for retirement pay during that same period. Because the appellant contends that he incurred or aggravated disabilities on the way to reporting for INACDUTRA on December 29, 1990, an issue in this case is the point at which the appellant entered into the status of INACDUTRA. It appears from the newspaper articles submitted by the appellant that his unit was supposed to report at the Armory by 0800 hours on December 29, 1990. It is clear from the evidence of record that the appellant was injured in a work-related accident on December 27, 1990; he claims to have aggravated those MVA-related injuries while he was on INACDUTRA on December 29, 1990. Both the appellant and his spouse have described a fall that occurred before he entered his vehicle and started the trip to the Armory. While neither section 106(d) of the statute nor section 3.6(e) of the regulations include the words 'portal-to-portal', review of the legislative history of Public Law 881, 84th Congress indicates that the phrase was discussed. See, e.g., Servicemen's and Veterans' Survivors' Benefits Act: Hearings Before the Select Committee on Survivors Benefits, 84th Cong., 1st Sess. 56-57 (1955). Although sections 106(d) and 3.6(e) and the pertinent legislative history include the terms 'proceeding', 'en route', 'travel', and 'using transportation facilities of his own choosing', there is no conclusive evidence that the reservist had to be using some mode of transportation before s/he would come under the purview of the legislation. On the other hand, there is no definitive evidence that the coverage extended from the point in time at which the reservist opened the door of his/her home to leave for INACDUTRA to the point in time at which s/he opened the door of the home upon return from INADUTRA. Purely for the sake of argument and to afford the appellant the most liberal possible interpretation, the Board will, however, assume such literal portal-to-portal coverage in analyzing the appellant's issues of entitlement to service connection. There has been no dispute that the appellant's original left knee condition -- which resulted in surgery when he was twelve years old -- preexisted his enlistment in the National Guard, and therefore was not incurred during ACDUTRA or INACDUTRA. This childhood condition is clearly documented in the record, and there has been no assertion or any indication that it occurred during any type of military duty. Furthermore, the Board notes that the pre-service July 1982 medical examination indicated that the left knee condition had preexisted the appellant's military service, that the condition had required surgery, and that degenerative changes were shown on x-rays. The Board finds such evidence sufficient to establish that the appellant's left knee disorder preexisted his military service. Likewise, the appellant admits that he suffered injuries to his left knee as a result of the December 27, 1990, motor vehicle accident. The medical evidence of record, including that relating to the appellant's associated Workers Compensation benefits, refers to the existence of the injury after the December 27, 1990, accident. The Board finds such evidence sufficient to establish that the appellant's left knee condition was aggravated by this accident. An increase in the severity of a preexisting condition, as distinguished from the mere recurrence of manifestations of the pre-service condition, is required to establish service connection for a preexisting injury or disease on the basis of aggravation. Evidence of temporary flare-ups symptomatic of an underlying preexisting condition, alone or without more, does not satisfy the level of proof required of a non-combat appellant to establish an increase in disability. Davis v. Principi, 276 F.3d 1341 (Fed. Cir. 2002). The appellant states that he suffered aggravation of that left knee injury as a result of his December 29, 1990 day of INACDUTRA. He and his wife maintain that the aggravation occurred while on his way to report for INACDUTRA on December 29, 1990. The appellant's representative has stated that the appellant contends that service connection for the left knee residuals is warranted because his left knee pathology was aggravated due to the events of December 29, 1990. See Board Hearing Transcript pp. 3-4 and p. 8-9. However, the appellant has supplied no competent evidence of record to indicate that any such aggravation of the claimed conditions occurred during the December 29, 1990, period of INACDUTRA. On the other hand, the appellant's treating orthopedist stated, in April 1991, that examination of the appellant's left knee was normal and the July 2015 VHA orthopedic specialist's opinion states that the appellant's left knee pathology was not permanently aggravated by the events of December 29, 1990. The Board also notes that the appellant and his spouse have described the aggravation of the claimed injuries as an increase in his pain level. However, pain alone, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), aff'd in part, vacated and remanded in part on other grounds by Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). The appellant has not provided any competent medical evidence to establish that his left knee pain was related to an aggravation of an underlying malady or that it represented any new malady. The appellant has argued that he suffered aggravation of his pre-existing left knee disorder/injury due to a fall in his driveway, due to the rigors of travel, and due to getting out of his car and into the Armory on December 29, 1990. Whenever any claim is filed alleging that the claimant is entitled to benefits by reason of 38 C.F.R. § 3.6(e), as in this case, the regulation states that the burden of proof shall be on the claimant. The appellant has not provided any competent proof that he suffered an injury or any aggravation of a pre-existing disorder/injury between the time he left his house on December 29, 1990, and the time he checked in at the Armory for his period of INACDUTRA on that day or during his travel back home that day. The Board also notes that the appellant's descriptions of his actions on that day have included the wearing a leg brace and a neck brace and using a crutch, as well as engaging in the moving/hauling of military equipment such as duffle bags, chairs, food service equipment, radio equipment and other equipment. While service connection may be shown directly or, for certain "chronic diseases," such as arthritis, presumed, if the disease manifested to a degree of 10 percent or more within one year after the date of separation from service, presumptive periods do not apply to ACDUTRA or INACDUTRA. Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Therefore, favorable application of 38 C.F.R. §§ 3.307, 3.309 (presumption of service incurrence), 3.306 (presumption of aggravation), and 38 U.S.C.A. §§ 1111, 1131 (presumption of soundness) is not available in this appeal. The Board does acknowledge that the appellant and his spouse have described the aggravation of the claimed injuries as an increase in his pain level. Indeed, his wife submitted a statement dated in June 2001 indicating that she is a registered nurse and that she witnessed him fall on his way to INACDUTRA. She also indicated that his pain intensified as a result of the incident. In another statement, received in October 2008, the appellant's spouse noted that after review of the appellant's medical records (without any specific description of the records reviewed), as a registered nurse, she knows for certain that the fall the appellant had while carrying his heavy duffle bags en route to military duty on December 29, 1990 aggravated his injured weight bearing joints to the extent that he was unable to perform his military duties on December 29, 1990. While at the Armory attempting to perform his military duties in excruciating pain on movement, the captain sent him home and the appellant was told to go to Troop Medical Clinic at Camp Robinson for medical evaluation. The appellant's spouse reported that she treated the appellant at home on December 29, 1990, and subsequently. She contends that the appellant suffers from a left knee disorder that was impacted by his military service on December 29, 1990. The Board notes that medical evidence is not limited to that which is provided by doctors. As provided by 38 C.F.R. § 3.159(a)(1), "competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions." The Court has held that a nurse practitioner fits squarely into the requirement of section 38 C.F.R. § 3.159(a)(1) as a provider competent to provide diagnoses, statements, or opinions. Similarly, in this case, the appellant's wife appears to be a registered nurse, and thus, she has completed medical education and training and meets the requirement of section 38 C.F.R. § 3.159(a)(1) as one competent to provide diagnoses, statements, or opinions. Cox v. Nicholson, 20 Vet. App. 563, 568-70 (2007). The appellant's spouse has opined that the appellant's fall en route to military duty on December 29, 1990 aggravated his injured weight bearing joints. In addition, she noted that the appellant was in a lot of pain. Nevertheless, pain alone, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), aff'd in part, vacated and remanded in part on other grounds by Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Moreover, even assuming that the appellant did have an increase in pain, the Board notes that aggravation for purposes of entitlement to VA compensation benefits requires more than that a preexisting disorder become intermittently symptomatic during service. An increase in the severity of a preexisting condition, as distinguished from the mere recurrence of manifestations of the pre-service condition, is required to establish service connection for a preexisting injury or disease on the basis of aggravation. There must be permanent advancement of the underlying pathology. In considering the evidence of record under the laws and regulation as set forth above, the Board concludes that the appellant is not entitled to service connection for a left knee disorder. As previously noted, whenever any claim is filed alleging that the claimant is entitled to benefits by reason of 38 C.F.R. § 3.6(e), as in this case, the regulation states that the burden of proof shall be on the claimant. The appellant has not provided sufficient evidence that he suffered an injury or any aggravation of a pre-existing injury between the time he left his house on December 29, 1990, and the time he checked in at the Armory for his period of INACDUTRA on that day or during his travel back home that day. The appellant's service treatment records dated in January 1991, February 1991, and April 1991 indicate that he did seek treatment for his left knee. It was noted that he had been injured on a motor vehicle accident on December 27, 1990. However, there was no indication the injuries had chronically worsened or increased in severity on December 29, 1990. In fact, his service treatment records do not document any complaints, treatment, or diagnosis pertaining to his claimed disorder on December 29, 1990, and subsequent records show that the lower extremities of the appellant were rated as having a high level of fitness in May 1991. The Board finds the determinations of the July 2015 VHA orthopedic surgeon indicating that the appellant's left knee pathology was not permanently aggravated by the December 1990 fall to be more probative and persuasive than the September 2013 private medical opinion of record and to be more probative and persuasive than the statements furnished by the appellant's spouse - registered nurse. The VHA medical opinion was based on a thorough and detailed examination of the claims file and was supported by adequate and persuasive rationales. Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the physician's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). In this case, it is not known what medical records were reviewed by the private physician or the registered nurse and the private medical opinion includes no rationale. The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, or based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Board also finds that the opinion of the registered nurse has little probative value because she did not provide a rationale for her opinion regarding the left knee in that she did not explain how she determined that it was the fall on December 29, 1990 that aggravated the appellant's left knee condition as opposed to the injury from the December 27, 1990 MVA nor did she explain how, in light of the April 24, 1991 letter from the appellant's treating orthopedic surgeon stating that the appellant's left knee was normal, she determined that the appellant's preexisting left knee pathology had been aggravated in some tangible way other than increased pain on December 29, 1990. As the VHA orthopedic surgeon provided a rationale for his conclusions, the Board finds that the July 2015 VHA opinion is entitled to greater probative weight than the September 2013 private nexus opinion, which does not provide a rationale. See Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012) (noting that "examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion"); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (noting that "most of the probative value of a medical opinion comes from its reasoning"). An evaluation of the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicator. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and whether or not and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). Given these circumstances, the Board finds that the September 2013 private medical opinion and the registered nurse opinions have little probative value in this matter. The Board also notes that competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). However, musculoskeletal pathology requires specialized training for a determination as to diagnosis and causation, and is not susceptible of lay opinions on etiology. Furthermore, x-ray findings are necessary for a diagnosis of DJD or arthritis; such testing requires specialized equipment and training and is therefore not susceptible to lay opinions. Therefore, the Board cannot give decisive probative weight to the opinions of the appellant about the origins of his claimed left knee pathology because he is not qualified to offer such opinions. As noted above, the appellant's lay statements may be competent to support his claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau; Buchanan, both supra. Thus, he is competent to say that he had left knee pain on December 29, 1990, and now, but he does not have the expertise to state that there is a relationship between his one day of INACDUTRA and any current left knee disorder; a medical opinion would be required. See Davidson, supra. The same holds true for the appellant's representative. Thus, the Board cannot give decisive probative weight to the opinions of the appellant or his representative as to the etiology of his claimed left knee pathology because they are not qualified with medical expertise to offer such opinions. In addition, to the extent that lay assertions are offered in an attempt to establish a medical finding of aggravation of the appellant's left knee disorder, such an attempt must fail. The matter of aggravation of a disability is within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). Because neither the appellant nor his representative has been shown to be other than a layperson without the appropriate medical training and expertise, neither of them is competent to render a probative (persuasive) opinion on a medical matter. Hence, the lay assertions in this regard have no probative value. Here, the medical evidence does not establish that the appellant's preexisting left knee disorder underwent a chronic worsening or permanent increase in severity. In fact, the appellant's treating orthopedist stated in April 1991 that an examination of the left knee was normal. Furthermore, the sick call slips dated in January 1991 only mentioned the appellant's off-duty motor vehicle accident and did not note any injuries during ACDUTRA or INACDUTRA and the appellant's lower extremities were upgraded from 3T on PULHES in May 1991 in connection with his medical evaluation board (MEB). Although the appellant's spouse is competent and credible to report on what she witnessed and to opine that the appellant's left knee disorder was aggravated by his fall, the documentary evidence, consisting of contemporaneous records, is more persuasive with respect to whether a left knee disorder was permanently aggravated. The Board is also cognizant of the appellant's own statements to the effect that he believes his preexisting left knee disorder was aggravated by his December 29, 1990 period of INACDUTRA. The Board notes that the appellant is competent to report his experience and symptoms in service, such as being injuring himself and experiencing pain. While lay persons are generally not competent to offer evidence which requires medical knowledge, such as opinions regarding medical causation or a diagnosis, they may provide competent testimony as to visible symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). A veteran can attest to factual matters of which he or had had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Federal Circuit has held that lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465(1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). In this case, the appellant is competent and credible to express that he experienced an injury and resulting pain when he was en route to report to his period of INACDUTRA. However, the Board finds that the documentary evidence is more persuasive than the appellant's statements that his preexisting left knee disorder was aggravated by his period of INACDUTRA on December 29, 1990. In fact, although the December 27, 1990 record shows that the appellant sustained an injury to the left knee as a result of an off-duty motor vehicle accident, the December 28, 1990 x-ray was normal. In addition, the appellant reported that he fell en route to INACDUTRA and, therefore, his left knee disorder was permanently aggravated. However, there are no records dated December 29, 1990, and the medical evidence only attributes the appellant's left knee pain to his off-duty motor vehicle accident. Indeed, the sick call slips dated in January 1991 only noted that the appellant suffered an injury to the left knee during an off-duty motor vehicle accident; there was no mention of any injuries or problems during ACDUTRA or INACDUTRA. Furthermore, the appellant's treating orthopedist stated in April 1991 (merely 4 months after the alleged permanent aggravation during INACDUTRA) that an examination of the left knee was normal - weighing against the appellant's assertions. Also, the appellant's lower extremities were upgraded from 3T on PULHES in May 1991 in connection with his medical evaluation board (MEB). The Board thus finds that the appellant's statements are inconsistent with the documentary evidence of record including the contemporaneous evidence demonstrating that the appellant's left knee disorder was related to his off-duty motor vehicle accident. Contemporaneous evidence has greater probative value than history as reported by the veteran. See Curry v. Brown, 7 Vet. App. 59, 68 (1994). Therefore, the Board finds that the documentary evidence of record, including the service treatment records and private treatment records, is more persuasive than the appellant's statements as to whether his preexisting left knee disorder was permanently aggravated by active duty, to include his December 2015 assessment that the July 2015 VHA medical opinion is speculative. Finally, the Board also acknowledges the June 2001 statement from the appellant's mother-in-law. She noted that the appellant was in a bad automobile accident in December 1990 and forced to go to war two days later which was the worst thing that could happen to him. She stated that he was in no shape to drive himself let alone make these painful aggravating trips. She noted that over the years, he has complained of left knee pain. While the Board appreciates her statement, the key issue in this case is whether the appellant's left knee disorder was permanently aggravated by his reported injury during his one day of INACDUTRA, not the pain that the appellant has experienced as a result of his left knee disorder. As explained above, the Board finds that the documentary evidence, consisting of the service treatment records and private treatment records, are the most persuasive with respect to this question than the appellant's mother-in-law's statement. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Based on the foregoing, the Board finds that the preponderance of the evidence is against the appellant's claim for service connection for a left knee disorder. Because the preponderance of the evidence is against the appellant's claim, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for a left knee disorder is not warranted, including on the basis of aggravation. ORDER Entitlement to service connection for a left knee disorder (lateral meniscectomy residuals) is denied ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs