Citation Nr: 1754931 Decision Date: 11/30/17 Archive Date: 12/07/17 DOCKET NO. 13-28 775 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for heart murmur. 2. Entitlement to service connection for a left knee condition. 3. Entitlement to service connection for a left hand condition. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jonathan Z. Morris, Associate Counsel INTRODUCTION The Veteran had active military service from February 10, 1969 to May 2, 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In February 2016, the Veteran testified before the undersigned Veterans Law Judge at a live videoconference hearing. A transcript of the proceeding is of record. This case was previously before the Board in March 2016, where it determined that new and material evidence had been received to reopen the claim of entitlement to service connection for heart murmur. The Board then remanded the remaining issues for further development. The RO continued the denial of the Veteran's claim, as reflected in the July 2016 Supplemental Statement of the Case (SSOC), and returned the claim to the Board for further review. The Board notes that there was substantial compliance with its March 2016 remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran's chronic left knee condition is causally related to, or aggravated by his military service. 2. The preponderance of the evidence is against a finding that the Veteran's chronic left hand condition is causally related to, or aggravated by his military service. 3. The Veteran had a heart murmur condition prior to entering service and it did not permanently worsen beyond its natural progression during his active service. 4. The Veteran's currently diagnosed heart murmur is not attributable to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee condition have not been met. 38 U.S.C.A. § 1131, 5107 (West 2014); 38 C.F.R. § 3.102, 3.303, 3.304 (2017). 2. The criteria for service connection for a left hand condition have not been met. 38 U.S.C.A. § 1131, 5107 (West 2014); 38 C.F.R. § 3.102, 3.303, 3.304 (2017). 3. A heart murmur condition clearly and unmistakably preexisted service and was not aggravated by service, and the presumption of soundness at entry is rebutted. 38 U.S.C.A. § 1111 (West 2014). 4. A heart murmur condition was not incurred in or aggravated by service. 38 U.S.C.A. § 1131, 5107 (West 2014); 38 C.F.R. § 3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, which 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). Ideally, this notice should be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, VA's duty to notify was satisfied by a letter sent to the Veteran in September 2010. The letter informed him of the evidence required to substantiate the claim, and of his and VA's respective duties in obtaining this necessary supporting evidence. The letter also advised him of how a "downstream" disability rating and effective date are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Moreover, the claim was subsequently readjudicated in the July 2013 Statement of the Case (SOC), as well as in additional SSOCs. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). He has had ample opportunity to respond or supplement the record, and has not alleged that any notice was less than adequate. Therefore, the Board finds that VA's duty to notify has been satisfied. Regarding the duty to assist, the Board notes that the claims file contains the Veteran's service treatment records (STRs), post-service medical records, and his contentions. The Veteran has not identified, nor does the record otherwise indicate, any other evidence relevant to his claim that has not been obtained. Furthermore, the Veteran was provided with VA examinations in November 2010 and May 2016. Upon review of the medical evidence, the Board concludes that these medical opinions, collectively, are adequate for the purpose of rendering a decision in this case. See 38 C.F.R. § 4.2; Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claim. Therefore, no further assistance to the Veteran with the development of evidence is required. II. Legal Criteria for Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, to successfully establish service connection, there must be competent and credible evidence showing (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the disease or injury incurred in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain "chronic diseases" may be presumed to have been incurred in or aggravated by service if they manifest to a degree of 10 percent or more within one year of a Veteran's separation from service. 38 C.F.R. §§ 3.307, 3.309(a). This presumption is rebuttable by probative evidence to the contrary. Id. When a chronic disease is shown in service, sufficient 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). To be "shown in service," the disease identity must be established and the diagnosis must not be subject to legitimate question. Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013); see also 38 C.F.R. § 3.303(b). 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. Walker, 708 F.3d at 1336. Service connection may also be granted on a secondary basis for a condition that is not directly caused by the Veteran's service. 38 C.F.R. § 3.310. In order to prevail under a theory of secondary service connection, the evidence must demonstrate an etiological relationship between (1) a service-connected disability or disabilities and (2) the condition said to be proximately due to the service-connected disability or disabilities. Buckley v. West, 12 Vet. App. 76, 84 (1998); see also Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, secondary service connection may also be found in certain instances when a service-connected disability aggravates another condition. See Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310(b). Thus, service connection may be established either by showing (1) direct service incurrence or aggravation, (2) an etiological relationship between the claimed condition and a service-connected disability, or (3) using applicable presumptions, if available. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In determining whether service connection is warranted for a disability, 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 preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104 (a); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303 (a). A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (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). When considering whether lay evidence is competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, supra. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board provide reasons for rejecting evidence favorable to the Veteran. III. Left Knee Condition The Veteran contends that his left knee condition had its onset during hand-to-hand combat training at Basic. See Board Hearing Transcript at 5. Having carefully considered this claim, in light of the evidence of record and the applicable law, the Board concludes that the most probative evidence is against the Veteran's claim. The Board will begin by addressing direct service connection. As noted above, the first element of direct service connection requires medical evidence of a current disability. In this case, the Veteran has a current diagnosis of left knee osteoarthritis. See May 2016 VA Examination. Therefore, the Veteran has satisfied the first element of service connection. As previously mentioned, the second element of direct service connection requires medical evidence, or in certain circumstances, lay testimony, of an in-service incurrence or aggravation of an injury or disease. Initially, although arthritis is considered to be a "chronic disease" under 38 C.F.R. § 3.309(a), to be presumed to have been incurred during service, such chronic disease must manifest to a compensable degree within one year of separation from active duty. In this case, the first mention of a left knee condition in the medical evidence of record is a January 2010 treatment record that reflects the Veteran complained of left knee pain, a history of arthritis and prior arthroscopic surgery, which is well beyond the permissible presumptive period. Similarly, February 2010 diagnostic testing revealed degenerative changes and a diagnosis of osteoarthritis was provided, which is likewise well beyond the permissible presumptive period. Thus, service connection on a presumptive basis, for left knee osteoarthritis, is not warranted. See Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). An STR dated April 1, 1969 reflects that the Veteran complained of bilateral knee pain. After a physical examination revealed mild tenderness in the area anterior to the medial collateral ligament bilaterally, the examiner indicated that there was an unknown etiology for the Veteran's knee. This is the only complaint of symptoms related to a left knee condition documented in the Veteran's STRs. In fact, the earliest post-service medical records demonstrating that the Veteran complained of, or was treated for, a left knee condition was in 2002/2003, which is many years after his separation from active duty. See December 2010 VA Medical Record (indicating that Veteran reported a past history of left knee arthroscopic surgery). This prolonged period without complaints or treatment is evidence that there has not been a continuity of symptomatology, and it weighs against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of his low back condition). Nevertheless, during the pendency of this appeal, the Veteran has asserted that he experienced left knee symptoms during his active military service, which have continued since his separation from service. Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. Savage v. Gober, 10 Vet. App. 488, 496 (1997). In this case, the Veteran's assertions that he has continuously experienced pain in his knee since his service are considered competent evidence. Layno, 6 Vet. App. at 469-70. However, after weighing the Veteran's assertions of continuity against the absence of in-service treatment records detailing a chronic disability and the prolonged period before the first documented post-service treatment and diagnosis, the Board finds that service connection for a chronic left knee condition is not warranted on the basis of a continuity of symptomatology since active service. 38 C.F.R. § 3.303 (b). Even though presumptive service connection is not warranted, the Veteran is not precluded from establishing service connection for a diagnosed disability with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). Regarding direct incurrence, as noted above, an April 1969 examination report reflects that the Veteran complained of bilateral knee pain, but a diagnosis of a chronic knee condition was not provided. Similarly, there is no other mention of any complaints of, or treatment for, a left knee condition within the remaining STRs. Following the Veteran's separation, the earliest documented evidence of any complaints or treatment for any left knee condition was over 30 years after his separation from service. The fact that a chronic condition was not shown for such a prolonged period after his period of active service weighs against a claim that it was related to service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (explaining that the Board may consider "evidence of a prolonged period without medical complaint," along with other factors in resolving a claim). The Veteran was afforded a VA examination in November 2010, where a diagnosis of a chronic left knee condition was not found. Following physical evaluation of the Veteran, the examiner stated that there is no pathology to render a diagnosis of a left knee condition and X-ray findings were within normal limits. The examiner further indicated that Veteran has normal range of motion without pain. In its March 2016 decision, the Board found the November 2010 VA examiner's medical opinion to be inadequate, because the examiner did not address the Veteran's own lay statements regarding his left knee symptoms nor did the VA examiner address the diagnosis of a left knee condition documented in the medical evidence of record. See Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). The Veteran was afforded another VA examination in May 2016, where he was diagnosed with left knee joint osteoarthritis. Following physical evaluation, the VA examiner opined that it is unlikely (less than 50% probability) that the Veteran's left knee condition is related to or had its onset during service. In support of this conclusion, the examiner first addressed the April 1969 STR documenting the Veteran's complaints of bilateral knee pain and stated that this medical record did not identify an injury and, thus, consisted of negative findings. Next, the examiner noted the lack of post-service medical records documenting a chronic knee problem and indicated that "the Veteran's statement of an ongoing syndrome post-service and current pathology does not match the minor issue he complained of in the service or the post work history" as a sheet metal worker. On the other hand, the examiner indicated that the Veteran currently has mild, age-related degeneration. The Board finds that the May 2016 VA examination was thorough and adequate and provided a sound basis upon which to base a decision with regard to the Veteran's service connection claim. See Barr v. Nicholson, 21 Vet. App 303 (2007). Additionally, the May 2016 VA medical opinion is highly probative, as it was prepared by a medical professional who reviewed the Veteran's pertinent medical history, conducted an in-person evaluation, and clearly assessed the nature of his left knee condition. Moreover, the examiner's opinions are based on reliable principles and are supported by other evidence of record. See Neives-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that most of the probative value of an opinion comes from the discussion of its underlying reasoning or rationale). Based on the foregoing, the Board finds that the preponderance of the evidence is against a finding that the Veteran's left knee condition is etiologically related to his active military service. Although he has maintained that his current condition is related to service, the most probative evidence indicates otherwise. The Board recognizes that the Veteran is competent to report symptoms that he perceives through his own senses, but these reports must be weighed against the medical evidence of record. See Layno v. Brown, 6 Vet. App. at 469. While the Veteran has attempted to establish a nexus through his own lay assertions, he is not competent to offer an opinion as to the etiology of his chronic left knee condition due to the medical complexity of the matter involved. Again, the Board notes that arthritis requires specialized training for a determination as to diagnosis and causation and, consequently, falls outside the realm of common knowledge of a layperson susceptible to lay opinions on etiology. Accordingly, the Veteran is not competent to render a nexus opinion or attempt to present lay assertions to establish a nexus between his current diagnosis and his active service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As the preponderance of the evidence is against a finding that the Veteran's current left knee condition is etiologically related to his active military service, the benefit of the doubt rule is not applicable in this case. See 38 U.S.C.A. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). IV. Left Hand Condition The Veteran claims that his left hand condition began after his hand was struck during basic training. See Board Hearing Transcript at 5. Having carefully considered this claim, in light of the evidence of record and the applicable law, the Board concludes that the most probative evidence is against the Veteran's claim. The Board will begin by addressing direct service connection. As noted above, the first element of direct service connection requires medical evidence of a current disability. In this case, the Veteran has a current diagnosis of left hand degenerative arthritis. See May 2016 VA Examination. Therefore, the Veteran has satisfied the first element of service connection. As previously mentioned, the second element of direct service connection requires medical evidence, or in certain circumstances, lay testimony, of an in-service incurrence or aggravation of an injury or disease. Initially, although arthritis is considered to be a "chronic disease" under 38 C.F.R. § 3.309(a), to be presumed to have been incurred during service, such chronic disease must manifest to a compensable degree within one year of separation from active duty. In this case, the first mention of a left hand condition in the medical evidence of record is a September 2007 outpatient record that reflects the Veteran reported a diagnosis of rheumatoid arthritis from 20 years prior, which is well beyond the permissible presumptive period. Similarly, during a March 2009 follow-up, the Veteran reported that a private physician told him he might have carpal tunnel syndrome, which is likewise well beyond the permissible presumptive period. Thus, service connection on a presumptive basis, for left hand arthritis, is not warranted. See Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). A February 1969 STR reflects that the Veteran complained of pain in his left hand over the distal metacarpal, which he attributed to having hit his hand while in close combat during basic training. An X-ray examination report indicates that diagnostic testing revealed findings within normal limits. A dorsal contusion was noted. Conversely, the earliest post-service medical records demonstrating that the Veteran complained of, or was treated for, a left hand condition was in 2007, which is many years after his separation from active duty. See September 2007 VA Medical Record. This prolonged period without complaints or treatment is evidence that there has not been a continuity of symptomatology, and it weighs against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of his low back condition). Nevertheless, during the pendency of this appeal, the Veteran has asserted that he experienced left hand symptoms during his active military service, which have continued since his separation from service. Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. Savage v. Gober, 10 Vet. App. 488, 496 (1997). In this case, the Veteran's assertions that he has continuously experienced pain in his left hand since his service are considered competent evidence. Layno, 6 Vet. App. at 469-70. However, after weighing the Veteran's assertions of continuity against the absence of in-service treatment records detailing a chronic disability and the prolonged period before the first documented post-service treatment and diagnosis, the Board finds that service connection for a chronic left hand condition is not warranted on the basis of a continuity of symptomatology since active service. 38 C.F.R. § 3.303 (b). Even though presumptive service connection is not warranted, the Veteran is not precluded from establishing service connection for a diagnosed disability with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). Regarding direct incurrence, as noted above, a February 1969 STR reflects that the Veteran complained of pain in his left hand over the distal metacarpal. While a dorsal contusion of the hand was noted, an X-ray examination report indicates that diagnostic testing revealed findings within normal limits. Following the Veteran's separation, the earliest documented evidence of any complaints or treatment for any left hand condition was over 30 years after his separation from service. The fact that a chronic condition was not shown for such a prolonged period after his period of active service weighs against a claim that it was related to service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (explaining that the Board may consider "evidence of a prolonged period without medical complaint," along with other factors in resolving a claim). The Veteran was afforded a VA examination in November 2010, where a diagnosis of a chronic left hand condition was not found. Following physical evaluation of the Veteran, the examiner stated that there is no pathology to render a diagnosis of a left hand condition and X-ray findings were within normal limits. The examiner further indicated that the Veteran has normal range of motion without pain. In its March 2016 decision, the Board found the November 2010 VA examiner's medical opinion to be inadequate, because the examiner did not address the Veteran's own lay statements regarding his left hand symptoms nor did the VA examiner address the diagnosis of a left hand condition documented in the medical evidence of record. See Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). The Veteran was afforded another VA examination in May 2016, where he was diagnosed with left hand arthritis. Following physical evaluation, the VA examiner opined that it is unlikely (less than 50% probability) that the Veteran's left hand condition incurred in or caused by his military service. In support of this conclusion, the examiner first addressed the February 1969 STR documenting a left hand dorsal contusion and stated that X-ray testing at the time revealed normal findings. Next, the examiner noted the absence of post-service medical records showing a left hand complaint until 2007, which the examiner then stated that the minor contusion with only one visit and no later complaint would not lead to a later disability. Moreover, the examiner noted the Veteran's report of working for years as a sheet metal worker after service without any evidence of a hand disability. Finally, the examiner clarified the Veteran's current diagnosis. The examiner noted that Houston VAMC Rheumatology previously determined that the Veteran does not have rheumatoid arthritis. Furthermore, the examiner indicated that carpal tunnel syndrome "can be ignored," because the Veteran's in-service contusion was dorsal and carpal tunnel syndrome is palmar. The examiner stated that a dorsal contusion would not lead to a palmar carpal tunnel syndrome. The examiner further stated that the Veteran's current complaint is in an area where he has degeneration, which the examiner noted the degeneration pattern on X-ray being consistent with aging degeneration. The examiner also stated that the Veteran's complaints of finger numbness have no relationship to his documented in-service injury. The Board finds that the May 2016 VA examination was thorough and adequate and provided a sound basis upon which to base a decision with regard to the Veteran's service connection claim. See Barr v. Nicholson, 21 Vet. App 303 (2007). Additionally, the May 2016 VA medical opinion is highly probative, as it was prepared by a medical professional who reviewed the Veteran's pertinent medical history, conducted an in-person evaluation, and clearly assessed the nature of his left knee condition. Moreover, the examiner's opinions are based on reliable principles and are supported by other evidence of record. See Neives-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that most of the probative value of an opinion comes from the discussion of its underlying reasoning or rationale). Based on the foregoing, the Board finds that the preponderance of the evidence is against a finding that the Veteran's left hand condition is etiologically related to his active military service. Although he has maintained that his current condition is related to service, the most probative evidence indicates otherwise. The Board recognizes that the Veteran is competent to report symptoms that he perceives through his own senses, but these reports must be weighed against the medical evidence of record. See Layno v. Brown, 6 Vet. App. at 469. While the Veteran has attempted to establish a nexus through his own lay assertions, he is not competent to offer an opinion as to the etiology of his chronic left hand condition due to the medical complexity of the matter involved. Again, the Board notes that arthritis requires specialized training for a determination as to diagnosis and causation and, consequently, falls outside the realm of common knowledge of a layperson susceptible to lay opinions on etiology. Accordingly, the Veteran is not competent to render a nexus opinion or attempt to present lay assertions to establish a nexus between his current diagnosis and his active service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As the preponderance of the evidence is against a finding that the Veteran's current left hand condition is etiologically related to his active military service, the benefit of the doubt rule is not applicable in this case. See 38 U.S.C.A. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). V. Service Connection for a Heart Murmur The Veteran contends that his heart condition had its onset during his service following a 2-mile run. However, he further argues, in the alternative, that if his heart murmur pre-existed his service, then it was permanently aggravated beyond its normal progression during his active duty. Specifically, the Veteran believes the aggravation of his heart condition occurred while on a 2-mile run during boot camp where he began to have shortness of breath and tightness in his chest. See, e.g., February 2016 Statement. Having carefully considered this claim, in light of the evidence of record and the applicable law, the Board concludes that the most probative evidence is against the Veteran's claim. The first and perhaps most fundamental requirement for any claim of entitlement to service connection is proof that the Veteran currently has the claimed disability. See 38 U.S.C.A. § 1131; Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the medical evidence of record has extensively documented the Veteran's diagnosis of a heart murmur since 1969. See, e.g., May 2016 VA Examination. Therefore, the evidence of record establishes that the Veteran has a current right knee disability. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has distinguished between those cases in which the preexisting condition is noted upon entry into service, and those cases in which the preexistence of the condition must otherwise be established. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); Horn v. Shinseki, 25 Vet. App. 231, 234 (2012); see also 38 U.S.C.A. § 1111. In a case where there is no preexisting condition noted upon entry into service, (such as the case here), the Veteran is presumed to have entered service in sound condition, and the burden falls to the government to demonstrate by clear and unmistakable evidence that (1) the condition preexisted service and (2) the preexisting condition was not aggravated by service. Wagner, 370 F3d. at 1345; Horn, 25 Vet. App. at 234; 38 U.S.C.A. § 1111. This statutory provision is referred to as the "presumption of soundness." Horn, 25 Vet. App. at 234. The veteran is not required to show that the disease or injury increased in severity during service before VA's duty under the second aggravation prong of this rebuttal standard attaches. VAOPGCPREC 3-2003 (July 16, 2003). The government may show a lack of aggravation by establishing by clear and unmistakable evidence "that there was no increase in disability during service or that any 'increase in disability [was] due to the natural progress of the' preexisting condition." Wagner, 370 F.3d at 1096 (quoting 38 U.S.C.A. § 1153). This burden of proof must be met by "affirmative evidence" demonstrating that there was no aggravation. The burden is not met by finding "that the record contains insufficient evidence of aggravation." Horn, 25 Vet. App. at 236-37. The Veteran need never produce any evidence of aggravation to prevail under the aggravation prong, even if clear and unmistakable evidence establishes that the disease preexisted service. In other words, in a "not noted at entrance" situation, the burden is never shifted back to the Veteran to show that his disability increased in severity during service. Id. If the government rebuts the presumption of soundness, then the veteran is not entitled to service-connected benefits. However, if the government fails to rebut the presumption of soundness, then the veteran's claim is one of direct service connection. Horn, 25 Vet. App. at 236-37; Wagner, 370 F.3d at 1096. Prior to the application of the presumption of soundness, there must be evidence that a disease or injury, which was not noted upon entrance into service, actually manifested or was incurred in service. Gilbert v. Shinseki, 26 Vet. App. 48 (2013). The presumption of soundness shields the Veteran from a finding that the disease or injury preexisted (and therefore was not incurred in) service by requiring VA to prove by clear and unmistakable evidence that a disease or injury manifesting in service both preexisted service and was not aggravated by service. Id. at 55. "Clear and unmistakable evidence" is an "onerous" evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be "undebatable." Cotant v. Principi, 17 Vet. App. 116, 131 (2003); Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (noting that clear and undebatable means that the evidence cannot be misinterpreted or misunderstood). With regard to the existence of a preexisting condition, at the outset, a preexisting heart condition was not "noted" at any enlistment examination in the Veteran's service treatment records (STRs). See January 1969 Examination. In this regard, to be "noted" within the meaning of the presumption of soundness statute, the condition must be recorded in the entrance examination report. 38 C.F.R. § 3.304(b); see also 38 U.S.C.A. § 1111; Crowe v. Brown, 7 Vet. App. 238, 245 (1994) (holding that the presumption of sound condition attaches only where there has been an induction examination in which the later-complained-of disability was not detected). Thus, the presumption of soundness applies in the present case. While the presumption of soundness applies in this case, there is nonetheless clear and unmistakable evidence of record that a heart condition pre-existed the Veteran's service. In determining whether a disorder pre-existed service, the Board has considered both medical and lay evidence of record. In May 2016, two separate VA cardiologists concluded that the Veteran's heart murmur condition clearly and unmistakably existed prior to his induction into service. The VA examiner stated that the congenital murmur documented in the April 1969 cardiologist note means "arising from birth." The examiner noted that the fact that no murmurs were detected on the January 1969 enlistment exam does not negate the fact that innocent or benign murmurs are not always heard on auscultation. See also April 1969 Cardiology Examination (indicating that the Veteran's heart murmur existed prior to enlistment); April 1969 Veteran Statement (acknowledging that he was being disqualified due to a pre-existing heart murmur); Doran v. Brown, 6 Vet. App. 283, 286 (1994) (finding that "as a matter of law, the presumption of soundness was rebutted by clear and unmistakable evidence consisting of the appellant's own admissions during clinical evaluations" during service). In light of the totality of the lay and medical evidence of record, the Board finds there is clear and unmistakable evidence that the Veteran's heart murmur pre-existed his period of active military service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). However, as stated above, rebutting the presumption of soundness is a two-part analysis. As there is clear and unmistakable evidence that the Veteran's heart murmur preexisted service, consideration must be given as to whether clear and unmistakable evidence exists to show that the condition was not aggravated during service, to fully rebut the presumption of soundness. In other words, "VA may not rest on the notion that the record contains insufficient evidence of aggravation. Instead, to fully rebut the presumption of soundness, VA must rely on affirmative evidence to prove that there was no aggravation." Horn, 25 Vet. App. at 236. In this regard, after carefully reviewing the evidence of record, the VA has met its high burden here. The Board finds there is clear and mistakable evidence of no aggravation. Stated another way, in the present case, there is no probative evidence suggesting an in-service aggravation of a preexisting heart murmur condition during service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). "[A]n increase in disability must consist of worsening of the enduring disability..." Davis v. Principi, 276 F.3d 1341, 1344 (Fed. Cir. 2002). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306; Falzone v. Brown, 8 Vet. App. 398, 402 (1995). See also Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002) (holding that evidence of a temporary flare-up, without more, does not satisfy the level of proof required of a non-combat veteran to establish an increase in disability). Accordingly, "a lasting worsening of the condition"-that is, a worsening that existed not only at the time of separation but one that still exists currently is required. See Routen v. Brown, 10 Vet. App. 183, 189 n. 2 (1997); see also Verdon v. Brown, 8 Vet. App. 529, 538 (1996). Evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the veteran's health and medical treatment during and after military service, as evidence of whether a preexisting condition was aggravated by military service. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). In this case, the Veteran was afforded VA examinations in November 2010 and May 2016. Following physical examination, review of the medical history, and consultation with another VA cardiologist, the May 2016 VA examiner stated that the Veteran's heart murmur condition, which clearly and unmistakably preexisted his service, was clearly and unmistakably not aggravated as a result of his active military service. Initially, the examiner indicated that the audible murmur from the November 2010 examination was more likely than not related to the murmur documented in the Veteran's STRs. However, the examiner stated that this murmur was noted to be a "flow murmur," which means a murmur of no clinical significance. The 2010 and 2016 echocardiograms both mention that the mitral valve and tricuspid valve had a "trace of insufficiency," which the examiner again noted emphasizes the benign nature of the heart murmur. Moreover, the examiner described this as an "innocent murmur" and then discussed pertinent medical treatise information from the American Heart Association Online. Ultimately, the examiner concluded that the point of whether the Veteran had the heart murmur before or during his military service (brief though it was), is irrelevant because the heart murmur has always been benign and continues to have no effect on his health. Additionally, the examiner further stated that genetic testing has revealed that the Veteran has a congenital abnormality called "XYY" syndrome and, consequently, a congenital heart condition is more likely in this case. Furthermore, the examiner noted that the symptoms the Veteran exhibited were documented as being from anxiety, rather than from a heart murmur. Lastly, the examiner reiterated that the medical evidence of record extensively shows that the heart murmur is of no clinical significance and, thus, was not aggravated by the Veteran's service. The Board notes that where there is evidence of the Veteran having been asymptomatic on entering service, and later developing symptoms of the pre-existing disorder, this does not constitute aggravation in the absence of evidence of an increase in the underlying disorder. See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002). As noted above, the May 2016 VA medical opinion is highly probative, as it was prepared by a medical professional who reviewed the Veteran's pertinent medical history, conducted an in-person evaluation, and clearly assessed the nature of his left knee condition. Moreover, the examiner's opinions are based on reliable principles and are supported by other evidence of record. See Neives-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that most of the probative value of an opinion comes from the discussion of its underlying reasoning or rationale). Here, while the Board finds the Veteran credible, his opinion indicating that his heart murmur condition was aggravated during service is less probative than the VA medical opinion because this assessment is complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). As to a determination of whether the Veteran's preexisting heart murmur was aggravated in service, the Board finds that the most probative evidence, as noted, establishes that any worsening of the heart murmur condition was not beyond its natural progression. The Board relies on the evidence as outlined above to support this determination. Further, since there is clear and unmistakable evidence that the pre-existing heart murmur was not aggravated during service for the purpose of rebutting the presumption of soundness (38 U.S.C.A. § 1111), it necessarily follows that such condition was not, in fact, aggravated during service (38 U.S.C.A. § 1110). The heart murmur was not aggravated by service in order to rebut the presumption of soundness. VA's General Counsel found that such a finding would necessarily be sufficient to rebut the presumption of aggravation under 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306(b). The Board further finds that the Veteran's currently diagnosed heart murmur is not otherwise attributable to service. As the preponderance of the evidence is against a finding that the Veteran's current heart murmur condition was aggravated by his active military service, the benefit of the doubt rule is not applicable in this case. See 38 U.S.C.A. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER 1. Entitlement to service connection for a left knee condition is denied. 2. Entitlement to service connection for a left hand condition is denied. 3. Entitlement to service connection for heart murmur is denied. ____________________________________________ M. H. Hawley Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs