Citation Nr: 1604799 Decision Date: 02/09/16 Archive Date: 02/18/16 DOCKET NO. 14-10 566 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for degenerative joint disease (DJD) and degenerative disc disease (DDD) of the thoracolumbar spine (claimed as low back disability). 2. Entitlement to service connection for DJD of the right knee (claimed as right knee disability). 3. Entitlement to service connection for DJD of the left knee (claimed as left knee disability). 4. Entitlement to service connection for residuals of traumatic brain injury (TBI) (claimed as head trauma). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The Veteran served on active duty from July 1969 to July 1971 and from October 1974 to August 1993. These matters are before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision of the New Orleans, Louisiana Department of Veterans Affairs (VA) Regional Office (RO). In October 2015, a Travel Board hearing was held before the undersigned; a transcript is associated with the record. At the hearing the Veteran granted waiver of initial consideration by the RO of any additional evidence received, and pursuant to the Veteran's request, a 60-day abeyance was granted to allow for the submission of additional evidence. The issue of entitlement to service connection for residuals of TBI (claimed as head trauma) is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A chronic low back disability was not manifested in service, arthritis of the lumbar spine was not manifested within one year after the Veteran's separation from service, and no diagnosed low back disability is shown to be related to his service. 2. A right knee disability is not clearly shown at any time. 3. A chronic left knee disability was not manifested in service, arthritis of the left knee was not manifested within one year after the Veteran's separation from service, and no diagnosed left knee disability is shown to be related to his service. CONCLUSIONS OF LAW 1. A chronic low back disability was not incurred in or caused by the Veteran's active duty service, nor may it be presumed to have been incurred in such service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2015). 2. Service connection for a right knee disability is denied. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2015). 3. A chronic left knee disability was not incurred in or caused by the Veteran's active duty service, nor may it be presumed to have been incurred in such service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. By correspondence dated in January 2010, VA notified the Veteran of the information needed to substantiate his claims, to include notice of the information that he was responsible for providing and of the evidence that VA would attempt to obtain, as well as how VA assigns disability ratings and effective dates of awards. The Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. Private treatment records requested from Slidell Memorial Hospital and Delta Imaging are unavailable. A May 2010 letter from Slidell Memorial Hospital notes the Veteran had no treatment at that facility for the dates requested. A June 2011 letter from Delta Imaging informed VA that the Veteran did not have any medical treatment with them. He has been afforded VA examinations for the back and knees to evaluate those disabilities; and the Board finds the examination reports of the back and left knee are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). While both knees were examined on February 2014 VA knee examination, the RO did not arrange for a medical nexus opinion for the claimed right knee disorder because it was not necessary. Absent any evidence of a nexus between the claimed right knee disorder and service (i.e. of a related event, disease or injury therein), securing a medical nexus opinion is not warranted. See 38 C.F.R. § 3.159(c)(4). Even the low threshold standard endorsed by the United States Court of Appeals for Veterans Claims (Court) in McClendon v. Nicholson, 20 Vet. App. 27 (2006) is not met. The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist (as to the matters decided) is met. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that an RO official or VLJ who conducts a hearing fulfill two duties: (1) to fully explain the issues and (2) to suggest the submission of evidence that may have been overlooked. The transcript of the October 2015 video conference hearing reflects the undersigned specifically identified the issues on appeal and focused on the elements necessary to substantiate the claims and identified evidence that could assist the Veteran in substantiating the claims. A deficiency in the conduct of the hearing is not alleged. The Board finds that, consistent with Bryant, the duties set forth in 38 C.F.R. § 3.103(c)(2) were satisfied. Significantly, it is not alleged that notice in this case was less than adequate. Legal Criteria, Factual Background and Analysis Service connection may be established for disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for the claimed disorder, there must be evidence of: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, a nexus to service may be presumed where there is continuity of symptomatology since service. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The Veteran served in combat in Vietnam. See 38 U.S.C.A. § 1154(b). Notably, he was awarded a combat medical badge, and is therefore entitled to relaxed evidentiary standards afforded to combat Veterans under 38 U.S.C.A. § 1154(b). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is needed where the determinative question is one requiring medical knowledge. Id. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. It may also mean statements conveying sound medical principles found in medical treatises, and may include statements in authoritative writings, such as medical and scientific articles and research reports. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board has reviewed the entire record, with an emphasis on the evidence relevant to this appeal. Although the Board must provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, in the present claims. Low Back Disability The Veteran contends that he has a current chronic disability of the low back that was incurred due to injuries in service. STRs show he was seen in November 1976 with pain in the right side of his back near the sacrum that he sustained while playing basketball. The assessment was pulled tendon. In a July 1989 Report of Medical History (over 40 physical) the Veteran noted he had not ever had recurrent back pain, arthritis, or bone, joint or other deformity. The July 1989 Report of Medical Examination showed normal spine and other musculoskeletal on clinical evaluation. On February 1993 Report of Medical Examination (pre-ROTC Appointment) there were no abnormalities of the spine, or other musculoskeletal. In the associated Report of Medical History he specifically noted he had not ever had recurrent back pain, arthritis, or bone, joint or other deformity. X-rays of the lumbar spine in June 2009 show mild lumbar degenerative changes. VA outpatient clinic treatment records are negative for treatment of a low back disorder. On February 2014 VA back examination, the Veteran reported he suffered a lumbar spine strain in service in February 1976 playing ball. He was diagnosed with "strain" and was off a few days. He had no limitations the last active year of service. He has not been to a doctor's visit for his low back since service, but has been seen and diagnosed with bilateral hip problems. He reported having monthly pain at his beltline without radiation. He did not have radicular pain or any other signs or symptoms due to radiculopathy. There were no scars. There were no other pertinent physical findings, complications, conditions, signs or symptoms. Arthritis was documented on x-rays. The diagnosis was age typical DJD and DDD, diagnosed in 2014. The examiner opined that the lumbar spine is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale for the opinion was there were minimal problems in the military and post discharge; recent age-typical x-rays and examination show no evidence of any residual from military service events. In a statement in the Veteran's March 2014 Substantive Appeal/VA Form 9, he noted that the initial trauma to his back was while he was on active duty playing sports. He stated "As with most back injuries, a trauma or weakening of the back leaves the back susceptible to recurrent back injuries/problems. It also progresses and becomes arthritic with age. I now have developed DDD from this initial trauma....The records at the time of injury would not reflect DDD because the injury was new and had not become arthritic at that time. To expect that with a new injury is not of sound medical judgment. My [back] was injured on active duty, the doctor agrees and this should be rated [service connected]." At the October 2015 videoconference hearing the Veteran testified as to his military occupational specialty in the Army stating that he started out as a medic in Vietnam working with the Infantry and then went into field artillery. His duties while in the Army required him to put heavy stress on his knees and back. In Vietnam he carried a backpack with his regular combat stuff and the medical bag, which weighed approximately 100 to 110 pounds or more, for the 18 months he was there, 12 of which were in the field. When he went in field artillery he would shoot combat rounds that weighed 95 to 200 pounds and constant lifting was required "day in and day out[.]" While in the service and as a result of the heavy loads he carried around, he experienced pain, soreness and discomfort of the back. He would take a pain pill or just put up with the pain. He testified further that in addition to carrying "heavy stuff" that stressed his back in service, he also sprained his back in service playing ball. He stated that from that point on, his back would ache a little bit. He never went to the doctor for his back during service; he stated that he has not seen a doctor related to his back. When the weather changes his back aches. The Veteran's wife testified that she has known him to have back problems for 20 to 25 years, beginning in the late 1990's. The preponderance of the evidence is against a finding that a chronic low back disability was noted in service. While there is a notation in the STRs of a 1976 in-service back injury (pulled tendon), STRs subsequent to the 1976 back injury shows no complaints, treatment, findings or diagnosis of a low back disability. The Board has also considered his statements that in Vietnam he lifted and carried heavy equipment and ammunition and notes that his testimony is consistent with the circumstances of his combat service. However, later assessments of the back in service, after his 1976 back injury and after his return from Vietnam, affirmatively show physical examinations revealed a normal spine and the Veteran denied back complaints. See July 1989 and February 1993 examination reports. The Veteran specifically stated "no" to the question regarding recurrent back pain on July 1989 and February 1993 (towards the end of service), medical history reports. Significantly, the 2014 VA examiner found there was no evidence of any residuals from military service events. The evidence is also against a finding that a chronic low back disability was clinically noted postservice prior to the June 2009 x-rays of the lumbar spine that shows mild lumbar degenerative changes. Consequently, service connection for a low back disability on the basis that such disability became manifest in service and persisted is not warranted. As arthritis is not shown to have been manifested in the first postservice year, the chronic disease presumptive provisions of 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309 do not apply. In this regard, the first diagnosis of degenerative changes by x-ray in the record was many years after service, in 2009. Service connection is also not warranted on the basis of continuity of symptomatology under 38 C.F.R. § 3.303(b). The Veteran's testimony at the hearing and that of his wife appear to indicate that he is reporting continuity of back pain since service when he injured his back in 1976 and carried heavy loads in Vietnam. While the Veteran and his wife are competent to describe observed symptoms such as back pain and wincing, the preponderance of the evidence is against finding chronicity in service and continuity since. The STRs show the Veteran complained of back pain in November 1976, and was assessed with a pulled tendon. The fact that the Veteran denied any history of recurrent back pain on July 1989 and February 1993 reports of medical history does not support a finding of chronicity in service and continuity since. The Board finds more probative and persuasive the contemporaneous STRs reflecting no back abnormality in his later years of service than the recollections of the Veteran and his wife made many years after the time period in question. For the foregoing reasons, continuity of symptomatology has not been established, either by the clinical record or by statements of the Veteran (or his wife). Accordingly, the preponderance of the evidence is against the claim of service connection for a low back disability based on continuity of symptomatology under 38 C.F.R. § 3.303(b). Furthermore, the preponderance of the evidence is against a finding that the Veteran's current low back disability is related to his service. As noted above, the 2014 VA examiner deemed there were minimal problems during service and following separation from service; and recent X-rays and examination show no evidence of any residual from military service events. Instead the examiner attributed the DDD and DJD in the spine to age. The Board finds the February 2014 VA examination to be entitled to great probative weight, as it took into account review of the Veteran's record to include his medical history. The examiner's opinion that the lumbar spine is less likely than not incurred in service was based on a physical examination complete with X-rays and includes a historically accurate explanation of rationale that cites to factual data. The Board acknowledges the Veteran's assertions that he has a low back disability due to his service; although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the probable etiology of a disorder such as arthritis falls outside the realm of common knowledge of a lay person. He has no demonstrated or alleged expertise in determining a medical nexus, and he does not offer any supporting medical opinion or medical treatise evidence. Therefore, his opinion in this matter has no probative value. The preponderance of the evidence is against a finding that any current low back disability is related to service. The persuasive medical evidence is to the effect that the chronic disorder diagnosed after service was not actually manifested during service. The evidence is not in a state of equipoise on the question of nexus between any diagnosis of a low back disability and the Veteran's service. Accordingly, the Veteran's claim of service connection for a low back disability must be denied. Right and Left Knee Disabilities The Veteran contends he has right and left knee problems related to injuries that occurred in service. STRs show that in July 1983 the Veteran was seen with a sore knee (for 2 days); the knee was scraped knee secondary to sliding into base (it was not noted which knee it was). The assessments were abrasion and contusion. A March 1989 STR shows the Veteran reported to the BAS [Battalion Aid Station] for a left knee twist. He stated he was jumping off a tracked vehicle and fell in a hole. The assessments were rule out hyperextension and strain of plantaris muscle. That same day he was seen at the general dispensary with mild effusion, and pain with straightening the left knee. The assessment was strain of the left knee. A knee brace was prescribed/recommended and no physical training for 3 weeks. The July 1989 Report of Medical Examination shows the Veteran's musculoskeletal and lower extremities as normal on clinical evaluation. In the July 1989 Report of Medical History (over 40 physical) he noted he had swollen or painful joints, which the physician described as stretched muscles in the left knee; that report also noted he had not ever had "Trick" or locked knee, arthritis, or bone, joint or other deformity. On February 1993 Report of Medical Examination (pre-ROTC Appointment) there were no abnormalities of the musculoskeletal or lower extremities. In the associated Report of Medical History he specifically noted he had not ever had swollen or painful joints, "Trick" or locked knee, arthritis, or bone, joint or other deformity. In a statement in the Veteran's March 2014 Substantive Appeal/VA Form 9, he noted that he was treated for a left knee injury on active duty. He noted that he played a lot of sports while on active duty (football, baseball and basketball) and all of them provided extreme repetitive trauma to his knees. The combination of playing sports and physical training created a knee condition, which he had when he was released from active duty. On February 2014 VA knee examination, the Veteran reported he suffered a left knee injury in service in March 1989 playing ball. After the injury, he had a few days off, and there was no limitation in his last active year. After retirement he worked as a JROTC instructor. A few years post discharge from service he had a torn knee cartilage, and had knee surgery; no other knee events were noted. On examination, he did not have tenderness or pain to palpation for joint line or soft tissues of either knee. Muscle strength was normal for both knees. It was noted he had not had any meniscal conditions or surgical procedures for a meniscal condition. He had not had arthroscopic or other knee surgery. He did not have any residual signs and/or symptoms due to arthroscopic or other knee surgery. He did not have any scars. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms related to the knee. Degenerative or traumatic arthritis was documented by x-ray of the left knee. Osteoporosis was shown. The diagnoses were post medial meniscectomy after military service era and mild age-typical DJD/osteoporosis of the knee. The examiner opined that the left knee is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale for the opinion was there were minimal problems in the military and post discharge and recent age-typical x-rays and examination show no evidence of any residual from military service events. At the October 2015 videoconference hearing the Veteran testified that his duties while in the Army required him to put heavy stress on his knees. While in service and as a result of the heavy loads he carried around, he experienced pain, soreness and discomfort of the knees. He specifically injured his right knee playing in a softball tournament. He was sliding into base and got hung up in the bag, flipped over and twisted his right knee. He was taken out of the game, the knee was wrapped in an ace bandage, he used a cane for a while and it eventually got better. He stated that after he retired from military service, he learned he had torn cartilage from his private physician, Dr. Bolton, and had arthroscopic surgery in the late 1990s or early 2000s to cut away the torn cartilage on the knee. The operation was performed at Slidell Memorial Hospital. He stated he did not injure his knee after he got out of the service. He reported that he still has problems with his right knee, when bending and with weather changes (cold or rain). The Veteran stated that he has experienced right knee problems for about 20 years. Other than Dr. Bolton and the orthopedic surgeon he testified that he recalled no one else who treated his knee; and he is not currently receiving treatment for his right knee. The Veteran testified that he lost his copy of Dr. Bolton's treatment and the treatment at Slidell Memorial Hospital in Hurricane Katrina, and that his wife believed it would be difficult to get Dr. Bolton's records as he had been retired for "probably 10 years." At the hearing, the Veteran requested and was granted a 60-day abeyance period to attempt to contact Dr. Bolton in reference to information regarding the surgery, but no records were subsequently provided. He stated he injured his left knee while training in Germany. He was climbing a tractor, jumped down and twisted/sprained his left knee. The Veteran's wife testified that she witnessed the inservice injury to the right knee. She stated that he was sliding and something went wrong and he was helped off the field. She remembered having to care for him for a while after the incident. The Army doctor at Fort Sill gave him a knee brace and he was put on light duty. She stated that problems with his right knee started before he got out of the service, and has gotten progressively worse. On review, regarding the right knee, the threshold requirement here (as in any claim seeking service connection) is that there must be competent evidence that the Veteran has (or during the pendency of the claim has had) the disability for which service connection is sought, i.e., a right knee disability. See 38 U.S.C.A. §§ 1110, 1131. Service treatment records do not clearly diagnose the Veteran with any complaints, treatment or diagnosis with respect to the left knee. As noted, the STRs identify a left knee injury and an incident involving an abrasion and contusion to the knee; however, the specific knee involved is not identified. The VA examination conducted in February 2014 also did not clearly diagnose him with having a right knee disability. The examiner was unable to determine which knee had had a surgical procedure as no knee scars were found. While the Veteran and his wife testified during his hearing that he injured his right knee in service at a softball game prior to 1989, during the 2014 VA examination the Veteran reported that he suffered a left knee injury in service playing ball in March 1989. The Veteran testified at the videoconference hearing that due to his military duties he experienced pain and soreness of both knees. The evidence shows he never sought treatment in service for any such complaints. He stated specifically that he injured his right knee playing in a softball tournament. His STRs confirm that he scraped his knee sliding into base (he sustained abrasion and contusion), but does not identify which knee was injured. While the Board finds the Veteran (and his wife) is sincere in his recollection of events surrounding a knee injury, it has carefully reviewed the record in depth, and has been unable to identify medical evidence of a diagnosis of a right knee disability. Notably, the treatment records associated with the record do not show any diagnosis or treatment for any right knee disability. The Veteran's contentions do not support a finding that he has had persistent or recurrent symptoms of a right knee disability. Significantly, the Veteran has not submitted records that confirm the alleged postservice right knee arthroscopic surgery and the record is void of any treatment of symptoms associated with his right knee. Accordingly, there is no valid claim of service connection for a right knee disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). With respect to the left knee, the preponderance of the evidence is against a finding that a chronic left knee disability was noted in service. Despite the 1983 knee abrasion and contusion and the 1989 assessments (regarding the left knee) of rule out hyperextension and strain of plantaris muscle, STRs subsequent to the 1983 and 1989 knee injuries show no complaints, treatment, findings or diagnosis of a left knee disability. In the July 1989 medical history report, the Veteran specifically stated he had swollen or painful joints (described as stretched muscles in the left knee). He also responded "no" (indicating he had not had) to the questions regarding knee problems (tricked or locked knee), arthritis or bone, joint or other deformity. On the February 1993 (towards the end of service) medical history report he responded "no" to the same questions, including "no" to having had swollen or painful joints. It is noteworthy that even though the Veteran reported having swollen or painful joints related to the left knee in 1989, approximately 4 years later on examination in 1993 (close to the time of his separation from service) he reported that he did not have swollen or painful joints. Furthermore, the 2014 VA examiner found there was no evidence of any left knee residuals from military service events. The evidence is also against a finding that a chronic left knee disability was clinically noted postservice prior to the February 2014 VA examination that showed arthritis of the left knee documented by x-ray. Consequently, service connection for a left knee disability on the basis that such disability became manifest in service and persisted is not warranted. As arthritis is not shown to have been manifested in the first postservice year, the chronic disease presumptive provisions of 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309 do not apply. In this regard, the first diagnosis of degenerative or traumatic arthritis by x-ray in the record was many years after service, in 2014. In consideration of the above evidence, the preponderance of the evidence is against a finding of continuity of symptomatology to support the Veteran's claim under 38 C.F.R. § 3.303(b). To the extent the Veteran asserts continuity of symptomatology with respect to either knee, the STRs indicate that after the reported incidents involving injuries to the knees, he subsequently had no abnormalities of the lower extremities on clinical evaluation on medical examinations in July 1989 and February 1993. Further, he denied having any history of swollen or painful joints, trick or locked knee, arthritis, or bone, joint or other deformity on the February 1993 report of medical history. This report of medical history indicates a break in continuity subsequent to the reported injury. For these reasons, the Board finds the preponderance of the evidence is against a finding of continuity since the reported incidents involving injuries to the knees in service. Furthermore, the preponderance of the evidence is against a finding that there is a disability of either knee that is related to service. A VA opinion stated the Veteran's current left knee disability is not related to his service but instead is due to his age. As support for his conclusion, the 2014 VA examiner deemed there were minimal problems during service and following separation from service. The examiner also noted that recent x-rays and examination show no evidence of any residual from military service events but instead showed findings that were age-typical. The Board finds the February 2014 VA examination to be entitled to great probative weight, as it took into account review of the Veteran's record to include his medical history. The examiner's opinion that the left knee is less likely than not incurred in or caused by service was based on a physical examination complete with x-rays and includes a historically accurate explanation of rationale that cites to factual data. The Board acknowledges the Veteran's assertions that he has a left knee disability due to his service; although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the probable etiology of a disorder such as arthritis falls outside the realm of common knowledge of a lay person. He has not demonstrated or alleged expertise in determining a medical nexus, and he does not offer any supporting medical opinion or medical treatise evidence. Therefore, his opinion in this matter has no probative value. The preponderance of the evidence is against a finding that any current left knee disability is related to service. The persuasive medical evidence is to the effect that the chronic disorder diagnosed after service was not actually manifested during service. The evidence is not in a state of equipoise on the question of nexus between any diagnosis of a left knee disability and the Veteran's service. Accordingly, the Veteran's claim of service connection for a left knee disability must be denied. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claims of service connection for low back, right knee and left knee disabilities. Accordingly, they must be denied. In denying these claims, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claims, the doctrine is not for application. ORDER Service connection for a low back disability is denied. Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. REMAND STRs show that in March 1976 the Veteran complained of having headache after receiving a blow to the frontal area of his skull. He suffered lacerations that were closed with sutures. Neurological signs were normal. The assessment was post-concussion headache. In a July 1989 Report of Medical History (over 40 physical) the Veteran noted he had head injury (head busted open by hydraulic jack). On February 1993 Report of Medical History he noted he had head injury ("Hit in head by Hydraulic Jack throw[n] out from under a track vehicle'). On February 2014 VA neurological TBI examination, the Veteran was diagnosed with TBI (diagnosed February 2014). At the examination, he complained of having some memory problems; he expressed that they were slowly coming on. He stated that he forgets what his wife tells him to do. On examination, the examiner reported that his judgment was normal; his social interaction was routinely appropriate and he was always oriented to person, time, place, and situation. His motor activity was normal. He described subjective symptoms as "uses GPS or a map[.]" There were no neurobehavioral effects noted. He was able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language. He had normal consciousness. It was further noted that he did not have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease). The examiner concluded the Veteran had no apparent residuals from what sounds like a mild TBI suffered at the time of a head laceration in 1976. At the October 2015 videoconference hearing, the Veteran stated that he cannot remember. His wife reported that he has short-term memory loss. He testified that he was not going to say he had problems with headache after the injury, but he just does not remember things and he gets confused or lost sometimes. He stated that he has gaps in his memory and does not know if he has blackouts. He also has problems sleeping. When asked why he thinks his memory and sleeping problems are related to the head injury in service, he responded, "That's the only thing I can think of to cause a memory lapse." The Board notes that the examiner provided a diagnosis of TBI (diagnosed February 2014). The Veteran's complaints of memory loss were noted in the examination report. The examiner opined that the Veteran has no apparent residuals from what sounds like a mild TBI suffered at the time of a head laceration in 1976. Based on the examiner's opinion, it is not clear whether she considered the Veteran's complaints of memory loss (which he relates to the inservice head injury) in formulating her opinion as her opinion contradicts the notation in the examination report that the Veteran experiences memory loss. Consequently, the Board finds that the February 2014 VA TBI examination is not adequate for rating the Veteran's claim. Once VA undertakes the effort to provide an examination, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the case is REMANDED for the following action: 1. Obtain any updated VA and private treatment records with respect to the TBI. 2. The AOJ should forward the record to the examiner who conducted the February 2014 VA TBI examination for review and an addendum opinion to identify whether the Veteran's complaints of memory loss are residuals of the in-service TBI. If the examiner who conducted the February 2014 VA TBI examination is unavailable, another opinion provider should prepare the opinion. An examination should only be performed if the new opinion provider finds that a new VA examination is necessary in order to secure the opinion sought. The rationale for all opinions should be provided. 3. The AOJ should then review the record and readjudicate the claim. If it remains denied, the AOJ should issue an appropriate supplemental statement of the case and afford the appellant and his representative opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs