Citation Nr: 1756737 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 11-06 899 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a left knee disorder, to include a Baker's cyst or residuals thereof. 2. Entitlement to service connection for a right knee disorder, to include as secondary to a left knee disorder. 3. Entitlement to service connection for a low back disorder, to include as secondary to a left knee disorder. 4. Entitlement to service connection for a bilateral hip disorder, status post-total hip arthroplasties (THP), to include as secondary to a left knee disorder. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD W.T. Snyder, Counsel INTRODUCTION The Veteran had active service from September 1966 to September 1968. His service included a tour in the Republic of Vietnam (RVN) from February 1967 to February 1968. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). It denied the bilateral knee, low back, and bilateral hip claims. In June 2016, the Veteran appeared at a Board hearing at the RO via video conference before the undersigned. He also appeared at a local hearing at the RO in July 2011 before a decision review officer. Transcripts of the testimony at both hearings are in the claims file. The Board remanded the case to the RO in April 2016 so the aforementioned hearing could be scheduled. The case also was remanded in April 2014 and February 2015 for additional development of the knees, back, and hips claim. In a decision dated in September 2016, the Board denied the Veteran's appeal regarding the above listed issues and remanded a bilateral hearing loss issue. While the case was on remand, in a December 2016 rating decision, service connection was granted for bilateral hearing loss with an initial 0-percent (noncompensable) rating, effective in October 2012. There is no indication in the claims file that the Veteran has appealed either the initial rating or effective date. Hence, that issue is not before the Board and will not be addressed in the decision below. See 38 C.F.R. § 20.200 (2017). The Veteran appealed the non-remand facets of the September 2016 decision to the United States Court of Appeals For Veterans Claims (Court). In July 2017, the Veteran, through his attorney, and the Secretary of Veterans Affairs, submitted a Joint Motion For Remand (JMR). In an Order also dated in July 2017, the Court granted the JMR, vacated the September 2016 Board decision, and remanded the case to the Board for further appellate review consistent with the JMR. Additionally, the Board noes an August 14, 2017 letter to the Veteran (with a copy to the above listed representative) updated the Veteran on the status of his case and various things he could do, such as submit additional evidence. This letter noted that if he wished to submit additional evidence he may return an attached form. The Veteran returned this form, dated August 21, 2017, and checked the option to remand the case back to the AOJ. Attached to this form was a letter from the Veteran's representative at the Court to the Veteran and what appears to be an excerpt from a brief filed at the Court. The Board finds the letter not to be evidence relevant to the merits of the appeal and the brief to be argument. As such, a remand for consideration of such argument is not necessary and would only result in additional delay. FINDINGS OF FACT 1. The Veteran is presumed to have been in sound condition upon entry into active service, as a pre-existing Baker's cyst of the left knee was not listed as a defect on the examination for induction. 2. Clear and unmistakable evidence shows the Veteran had a pre-existing Baker's cyst of the left knee that was not aggravated by his active service. 3. A currently diagnosed left knee disorder, to include degenerative joint disease (DJD) did not have its onset in active service, nor is it due to an injury or disease incurred in active service. 4. Currently diagnosed right knee, low back, and bilateral post-THP hip disorders did not have their onset in active service, are not due to an injury or disease incurred in active service, nor are they due to a service-connected disability. CONCLUSIONS OF LAW 1. The Veteran's left knee Baker's cyst clearly and unmistakably existed prior to service and did not increase in severity during his active service. 38 U.S.C. §§ 1110, 1111, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017); VAOPGCPREC 3-2003 (July 16, 2003). 2. The requirements for entitlement to service connection for a left knee disorder, to include DJD, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1154, 5107(b); 38 C.F.R. §§ 3.159, 3.303, 3.307(a), 3.309(a). 3. The requirements for entitlement to service connection for a right knee disorder, to include DJD, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1154, 5107(b); 38 C.F.R. §§ 3.159, 3.303, 3.307(a), 3.309(a), 3.310. 4. The requirements for entitlement to service connection for a low back disorder, to include DJD, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1154, 5107(b); 38 C.F.R. §§ 3.159, 3.303, 3.307(a), 3.309(a), 3.310. 5. The requirements for entitlement to service connection for a bilateral hip disorder, status post-THA, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1154, 5107(b); 38 C.F.R. §§ 3.159, 3.303, 3.307(a), 3.309(a), 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist Prior to issuance of the September 2009 rating decision, via letters dated in April 2009 and June 2009, VA provided the Veteran with notice. Additionally, VA has a duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. See 38 C.F.R. § 3.159(c). The Veteran's service treatment records (STRs), non-VA, and VA treatment records, including the VA examination reports are in the claims file. Further, as noted in the Introduction, the Board remanded the case for additional development, including examinations. The Board finds that the remand directives were substantially complied with. Neither the Veteran nor his representative has asserted that there are additional records to obtain. As such, the Board will proceed to the merits of the appeal. Governing Law and Regulations Generally, to establish service connection, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Arthritis is presumed to have been incurred in service if manifested to a compensable degree within one year of separation from service. This presumption applies to veterans who have served 90 days or more of active service during a war period or after December 31, 1946. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza elements in a claim involving a listed chronic disease is through a demonstration of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331, 1336-38 (Fed. Cir. 2013). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a chronic disease was "noted" during service or within the applicable presumptive period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. A disability which is proximately due to or the result of a service-connected injury or disease shall be service connected. 38 C.F.R. § 3.310. Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). 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, 469-70 (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"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage v. Gober, 10 Vet. App. 488, 495-97 (1997) (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). 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, 469-70 (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"). In relevant part, 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). A layperson is competent to report on the onset of disability and, when applicable, continuity of his or her current symptomatology. See Layno, 6 Vet. App. at 470 (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient to establish a diagnosis 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. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether an appellant's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. at 511, aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Left Knee/Baker's Cyst A veteran is presumed to have been in sound condition when enrolled for service, except for any disease or injury noted at the time of enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before enrollment and was not aggravated by such service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). When no pre-existing medical condition is noted upon entry into service, a Veteran is presumed to have been sound upon entry. 38 U.S.C. § 1111; Wagner, 370 F.3d at 1096; Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). If the presumption of soundness applies, the burden then shifts to the Government to rebut the presumption by clear and unmistakable evidence that the disability was both pre-existing and not aggravated by service. Wagner, 370 F.3d at 1096; Bagby, 1 Vet. App. at 227. As further explained in Horn v. Shinseki: Once the presumption of soundness applies, the burden of proof remains with the Secretary on both the preexistence and the aggravation prong; it never shifts back to the claimant. In particular, even when there is clear and unmistakable evidence of preexistence, the claimant need not produce any evidence of aggravation in order to prevail under the aggravation prong of the presumption of soundness . . . the burden is not on the claimant to show that his disability increased in severity; rather, it is on VA to establish by clear and unmistakable evidence that it did not or that any increase was due to the natural progress of the disease. 25 Vet. App. 231, 235 (2012). "The Federal Circuit has made clear that the Secretary may rebut the second prong of the presumption of soundness through demonstrating, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or (2) any increase in disability was due to the natural progression of the condition." Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009) (citing Wagner, 370 F.3d at 1096). This burden must be met by "affirmative evidence" demonstrating that there was no aggravation. See Horn, 25 Vet. App. at 235. The burden is not met by finding "that the record contains insufficient evidence of aggravation." Id. Discussion The Board notes that the parties specifically stated in the JMR, and discussed in more detail later in this decision, that they did not contest the above finding of the Board that the Veteran had a pre-existing Baker's cyst which clearly and unmistakably did not increase in severity during active service. (07/26/2017 CAVC Decision, 1st Entry, p. 2, FN 2) In as much as the September 2016 Board decision was vacated in its entirety, however, the Board again sets forth the discussion of the issue. See 38 C.F.R. § 20.1303 (stating the nonprecedential nature of Board decisions). The December 1965 Report of Medical History upon induction showed the Veteran reported that he had a leg operation at the University of Virginia (UVA) for a cyst in the knee. The examiner noted that it was asymptomatic. (04/21/2009STR-Medical, p. 11) A January 1964 discharge summary report from the UVA hospital noted treatment for left knee pain. A tomogram study revealed a Baker's cyst in the left knee, and a surgical excision was planned for the end of the Veteran's school year; however, there is no documentation that indicates that this operation was performed prior to the Veteran's induction. The December 1965 Report of Medical Examination for Pre-Induction reflects that no left knee disability was diagnosed, and that the lower extremities were assessed as normal. A subsequent entry noted in September 1966 confirmed no additional defects were discovered. Hence, the left knee is presumed to have been in sound condition when he entered active service. The Veteran's STRs reveal that he was treated for left and "right" knee pain. In a November 1966 clinical record, the Veteran complained of an old chronic knee problem which had previously been diagnosed as a Baker's cyst. In a March 1967 progress note, the Veteran was also treated for "right" knee pain. In a July 1967 orthopedic record, the treating clinician reported that the Veteran had been seen five times in the past four months for complaints of nocturnal pain in the left knee. The Veteran was noted to have extensive documentation of a Baker's cyst by an orthogram and he claimed that the pain was getting worse. The clinician referred the Veteran for medical treatment in Japan. The Veteran was hospitalized in July/August 1967. In a March 1968 clinical record, the Veteran continued to complain of aching pain in his left knee. A physical examination revealed normal circulation without grinding or rough movement. The examiner found no tenderness and the ligament was intact. In April 1968, the Veteran was also placed on a 60-day limited duty physical profile for chondromalacia. Due to the Veteran's recurrent complaints of left knee symptoms, and all of the negative examinations, the Veteran was even referred for a mental health assessment to evaluate whether his complaints were purely psychological. The mental examiner opined that the Veteran's complaints were not of psychiatric origin, as he in fact had the symptoms he reported, and he believed he was supposed to get surgery after his induction. On the August 1968 Report of Medical History for his examination at separation, the Veteran reported that he was treated for joints but the "EM says didn't help." He also reported his previous knee operation at UVA on 1964, and he had swollen and painful joints, leg cramps, and cyst condition. The August 1968 Report of Medical Examination for Separation reflects that the Veteran's spine and lower extremities were assessed as normal. At both the RO (07/18/2011 Hearing Testimony) and Board hearings, the Veteran's testimony was essentially the same. He denied having sustained any injury to the left knee, but he did experience continuous pain which-in his opinion, is proof that the left knee Baker's cyst increased in severity during his active service and impacted his back, hips, and knees. An August 2011 VA examination report reflects that the examiner conducted a detail review of the claims file and noted that, despite the Veteran's chronic in-service complaints of left knee pain that he attributed to a Baker's cyst, several evaluations and diagnostic tests did not reveal a Baker's cyst. All of the left knee examinations revealed normal findings. A 1968 X-ray of left knee did not reveal any internal structural alterations with the knee joint or patella, and his discharge physical of 1968 did not reveal any left knee residual. (08/04/2011 VA Examination) Pursuant to the Board's April 2014 remand, another examination was conducted. The December 2014 examination report reflects that the Veteran reported his history as reported at previous examinations. Although the examiner diagnosed the Veteran with Baker's cyst of the left knee, he opined that military service did not permanently aggravate any pre-existing conditions leading to a post-service condition. The Board remanded the case again in February 2015 with the instruction that either a physician or physician assistant review the claims file and render an opinion with application of the clear and unmistakable evidence standard, as the Veteran's left knee was deemed sound at induction. The May 2015 examination report reflects that the examiner, a physician, conducted a detail review of the claims file. The examiner acknowledged the questions on which the Board directed be answered and the correct legal standard of clear and unmistakable evidence. The examiner noted that the Veteran's report of his medical history as noted in the STRs and other evidence showed that his left knee symptoms related to a Baker's cyst clearly and unmistakably existed prior to service. The examiner opined that it was clear and unmistakable that the Veteran's Baker's cyst of the left knee was not aggravated beyond the natural progress of the disorder by his active military service. The examiner's rationale was that the natural progression of a Baker's cyst is for the condition to enlarge. Hence, any progression is natural, as the simple use of the leg may make that occur, but no event in service caused that. (05/26/2015 C&P Exam) The Board finds that the STRs fully support the examiner's opinion and rationale, as multiple evaluations conducted during active service, to include as part of inpatient treatment, failed to reveal a Baker's cyst. The Veteran's in-service symptoms were the same as his pre-service symptoms, left knee pain, including nocturnal pain. It is reasonable to infer that, were the cyst to have increased in size, it would have been detected. Further, even decades after active service, the Veteran's left knee pathology has not been diagnosed as a Baker's cyst. Hence, the Board finds the examiner's opinion highly probative on the issue and deserving of much weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board acknowledges the Veteran's personal opinion to the contrary, but the Board finds that opining on the matter currently before the Board requires medical training. There is no evidence that the Veteran has medical training. Hence, his opinion on the issue has little if any probative value. His lay reports of his history, to include those of pain before, during, and after service, have been fully considered. See 38 C.F.R. § 3.159(a). In light of the above, the Board finds that the evidence clearly and unmistakably shows that the Veteran had a pre-existing Baker's cyst which clearly and unmistakably did not increase in severity during active service, as shown by the absence of a post-service diagnosis of a left knee Baker's cyst. 38 C.F.R. §§ 3.303, 3.304. As concerns the currently diagnosed left knee disorder, the consensus of the parties in the JMR is that the September 2016 Board decision did not sufficiently discuss the potential applicability of 38 C.F.R. § 3.303(b), which would allow the claim to be proved on the basis of continuous symptomatology. This assertion is based on the Veteran's statement of continuous left knee pain in service, and continuously since. As noted earlier in the general requirements, § 3.303(b) applies solely to a chronic disease, such as arthritis, diagnosed during active service. See Walker, 708 F.3d 1335-36 (stating that a prerequisite for consideration under § 3.303(b), is that the disability must be listed under 38 C.F.R. § 3.309). As already discussed, the STRs do not contain any entries that note a diagnosis of left knee arthritis; and, the Veteran's lower extremities were assessed as normal at separation. The evidence of record is against a finding that arthritis manifested at least to a compensable degree within one year of separation from service. The earliest date for which there is evidence of left knee arthritis is the May 1989 VA Agent Orange Protocol, where the Veteran reported occasional left knee pain, and X-rays showed DJD. (05/30/2014 Medical Treatment-Government Facility, p. 8, 12) The VA physician in 2015 noted that a Baker's cyst was a historical diagnosis of many years ago, there is no current diagnosis of one, and it is unrelated to any present symptomology. Hence, in addition to the fact that there is no evidence that arthritis manifested to at least a compensable degree within one year of service, as the Board found above, the weight of the evidence also shows that the Veteran's continuous left knee pain was related to the pre-existing Baker's cyst, and not developing arthritis. The Board acknowledges the Veteran's competency to identify knee pain, but finds that he does not have the requisite medical training to make a diagnosis of an underlying disorder that may have been associated with the pain. See 38 C.F.R. § 3.159(a). Thus, the Board finds that the weight of the evidence is against the claim under 38 C.F.R. § 3.303(b). As concerns service connection on a direct basis, the examiner opined further that there is not at least a 50-percent probability that the currently diagnosed left knee disorder, to include arthritis, is causally related to the symptoms noted in the STRs, as arthritis is a function of chronic wear and tear and aging. That examiner stated that the current arthritis has no etiological relationship to a condition of the tendon running through the joint space and not a part of the joint itself. See Osteoarthritis Definition, Mayo Clinic, (last visited Sept. 30, 2016), http://www.mayoclinic.org/diseases-conditions/osteoarthritis/home/ovc-20198248 (defining it as the most common form of arthritis occurring "when the protective cartilage on the ends of your bones wears down over time" and noting that it "can damage any joint in your body") (emphasis added). The Board notes the fact that the Veteran has asserted that his current left knee disorder is due to the wear and tear of his military duties, which included having to lift and carry heavy artillery shells, and the other rigors of active service. Also noted is the Veteran's testimony that he received treatment for the left knee at a VA facility in the 1970s. Requests for related records from that time period did not produce any records. The Veteran's private treatment records, however, do not note a reported history of left knee symptoms dated back that far, other than the Veteran's report of his history of a left knee Baker's cyst. See 06/17/2009 Medical Treatment-Non-Government Facility. All of the VA medical examination reports, however, reflect that the current left knee disorder did not have its onset in active service, but many years after service. There is no evidence that left knee arthritis manifested at least to a compensable degree within one year of service. The evidence of record, to include as described above, supports the examiners findings and opinions. Thus, the Board finds that the preponderance of the evidence weighs against service connection on a presumptive and direct basis. 38 C.F.R. § 3.303, 3.307(a), 3.309(a). Right Knee, Low Back, and Bilateral Hips The Board notes that the JMR did not comment on the merits of the right knee, low back, and bilateral hips. It only noted that they were inextricably intertwined with the left knee issue. As previously noted, the September 2016 Board decision was vacated, so this analysis is essentially reproduced. Cf. Mathews v. McDonald, 28 Vet. App. 309, 315 (2016) (holding that the Board "is not permitted to sub silentio incorporate its reasons or bases from a prior remand order into a later decision"). Although the Veteran claimed entitlement to service connection for his right knee, low back, and bilateral hips as secondary to his left knee Baker's cyst, the Board also directed development on a direct service connection basis. The general requirements for direct and secondary service connection were set forth earlier in this decision and are incorporated here by reference. STRs contain no entries related to complaints of or treatment for right knee, low back, or bilateral hip complaints. There are a couple of references to the "right" knee that are related to the treatment of the Veteran's left knee, but they were followed with discussion of the left knee, which indicates that reference to the right knee were more than likely erroneous. As noted earlier, the August 1968 Report of Medical Examination for Separation reflects that the spine and lower extremities were assessed as normal. The Veteran testified at the Board hearing that he sought treatment for his back within two to three years after he returned to the U.S., and that he underwent the THAs in 2013 and 2014. He asserted that once his left knee went, then the other claimed joints followed because of the impact on his gait. VA records note that the Veteran underwent an Agent Orange Protocol review in May 1989. The examination report does not reflect any notation of complaints related to the right knee, low back, or hips. DJD of the left knee was noted. This is the earliest date documented for the presence of DJD of the left knee. All other extremities were assessed as normal. (05/30/2014 Medical Treatment-Government Facility, p. 8) Post-service treatment records showed that the Veteran was treated for right knee pain in December 1999 by Dr. D.B. The Veteran reported that his work was fairly strenuous, involving climbing over logs much of the day. A physical examination revealed some edema and mild tenderness but the Veteran had full range of motion. An X-ray of the right knee revealed that the bony structure of the right knee was normal. In a January 2000 treatment record, the Veteran reported that he did not have a history of any specific injury, yet he had experienced right knee pain within the last four to five weeks. A physical examination revealed tenderness over the lateral aspect of the knee, and the private physician opined a probable lateral meniscus tear in the right knee. An August 2003 X-ray of the right knee showed mild to moderate degenerative change and narrowing of the joint space but no bone to bone contact. The Veteran was diagnosed with degenerative changes within the right knee. A December 2005 X-ray of the pelvis and right hip showed no evidence of any significant degenerative arthritis, yet the examiner noted that the pain seemed to be primarily centered on the hip joint. (06/17/2009 and 06/22/2009 Medical Treatment-Non-Government Facility) The December 2014 and later VA examination reports reflect that the Veteran currently must use a wheelchair due to Guillain-Barre syndrome. The examination report reflects that X-rays showed degenerative disease of the lumbar spine and right knee. The hip X-rays revealed bilateral hip prosthesis that seemed normal, although the radiologist noted that the left hip appeared to have a small interruption in the normal curvilinear shape of the acetabular portion of the prosthetic device. The examiner opined that there was not at least a 50-percent probability that either the right knee, low back, or bilateral post-THA hips had onset in active service or is causally connected to active service. The examiner's rationale was that all of the current disorders had their origins in the years after the Veteran's active service. The May 2015 VA examination report reflects that the examiner opined that the DJD of the right knee, lumbar spine, and bilateral hips was due to the aging process. As the examiner performed a physical examination, noted the Veteran's relevant medical history, and provided a clear opinion with support, the Board finds this to be probative evidence weighing against the claim. The private treatment records do not note reports of right knee, low back or hip complaints that date back to active service. There is no evidence that DJD manifested at least to a compensable degree in either joint within one year of service. The Veteran's assertion of having received treatment within two to three years of his separation is still outside the one-year window. The evidence of record supports the examiners' findings and opinions and the Board places much weigh on this competent medical evidence. Thus, the preponderance of the evidence is against service connection on a presumptive and direct basis. 38 C.F.R. § 3.303, 3.307(a), 3.309(a). Since the Board denies entitlement to service connection for the left knee, there is no factual basis for entitlement to service connection for the right knee, low back, or bilateral hips as secondary to the left knee. 38 C.F.R. § 3.310. In sum, the Board finds that the weight of the evidence, to include the opinion of the 2014 VA examiner, is against the issues. In reaching this decision the Board considered the doctrine of reasonable doubt. As the preponderance of the evidence is against the Veteran's claims, however, the doctrine is not for application. Schoolman v. West, 12 Vet. App. 307, 311 (1999). (CONTINUED ON THE NEXT PAGE) ORDER Service connection for a left knee disorder, to include a Baker's cyst, is denied. Service connection for a left knee disorder, to include DJD, is denied. Service connection for a right knee disorder, status post-arthroscopy, to include DJD, and including as secondary to a left knee disorder, is denied. Service connection for a low back disorder, to include DJD, including as secondary to a left knee disorder, is denied. Service connection for a bilateral hip disorder, status post-THP, to include as secondary to a left knee disability, is denied. ____________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs