Citation Nr: 1802928 Decision Date: 01/12/18 Archive Date: 01/23/18 DOCKET NO. 11-20 822 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a headache disorder, to include as secondary to medication for service-connected disabilities. 2. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected degenerative disc disease with osteoarthritis of the lumbosacral spine, left hip strain, and/or right hip disability. 3. Entitlement to service connection for a right knee disorder, to include as secondary to service-connected degenerative disc disease with osteoarthritis of the lumbosacral spine, left hip strain, and/or right hip disability. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K.C. Spragins, Associate Counsel INTRODUCTION The Veteran had active service in the United States Army from June 1996 to September 1998. She also served in the Army Reserve from September 1998 to November 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in September 2009 and August 2010 from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In a February 2017 decision, the Board remanded the case to the Agency of Original Jurisdiction for additional development and adjudication. The case has since been returned to the Board for appellate review. The Board finds that the RO substantially complied with prior remand directives, to the extent possible, and no further action in this regard is warranted. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (concluding that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with the Board's remand instructions). FINDINGS OF FACT 1. The Veteran's headache disorder did not manifest in active service and is not otherwise related to service; and it was not caused or aggravated by medication for service-connected disabilities. 2. The Veteran's left knee disorder did not manifest in active service and is not otherwise related to service; and it was not caused or aggravated by her service-connected degenerative disc disease with osteoarthritis of the lumbosacral spine, left hip strain, and/or right hip disability. 3. The Veteran's right knee disorder did not manifest in active service and is not otherwise related to service; and it was not caused or aggravated by her service-connected degenerative disc disease with osteoarthritis of the lumbosacral spine, left hip strain, and/or right hip disability. CONCLUSIONS OF LAW 1. A headache disorder was not incurred in active service; and was not proximately due to, the result of, or aggravated by medication for service-connected disabilities. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 2. A left knee disorder was not incurred in active service; and was not proximately due to, the result of, or aggravated by service-connected degenerative disc disease with osteoarthritis of the lumbosacral spine, left hip strain, and/or right hip disability. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 3. A right knee disorder was not incurred in active service; and was not proximately due to, the result of, or aggravated by service-connected degenerative disc disease with osteoarthritis of the lumbosacral spine, left hip strain, and/or right hip disability. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist In this case, the Veteran was notified in an August 2002 letter that the Army had not found her service treatment records (STRs). The RO requested that she provide more information to help the Army obtain her records, or provide copies of any STRs in her possession. In September 2002, the Veteran returned a completed Request for Information Needed to Reconstruct Medical Data, but the Records Management Center (RMC) informed the RO that it did not have any records. However, the Veteran also provided copies of her STRs in September 2002. See January 2003 rating decision. In this regard, the Veteran has asserted that her STRs are incomplete as they do not show treatment that she received for headaches in Germany. See June 2017 VA examination. However, the Board notes that the available STRs contain numerous entries from the Veteran's service in Germany, entries concerning her reported in-service injury, as well as the examinations and reports of medical history from her enlistment and separation. As discussed in additional detail below, the Board does not find the Veteran credible in her assertion that she experienced headaches during service. Thus, any further attempts to obtain the Veteran's STRs would be futile with respect to this claim. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). Neither the Veteran nor her representative has raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Law and Analysis Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 247, 431 (2006). Service connection may also be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Headache Disorder Regarding the Veteran's service connection claim for a headache disorder, the Board notes that the Veteran has a current diagnosis of migraine, including migraine variants. See June 2017 VA examination. The Veteran contends that her migraine headaches began during service after she was electrocuted while working on a vehicle as a mechanic. See June 2017 VA examination. The Veteran described being thrown backwards after she touched a wrench to a battery that had not been unhooked. She reported that her headaches have been present since that time. According to the Veteran, she received treatment, including medications, for her headaches during service. She stated that her current migraines involved symptoms of light and sound sensitivity, nausea, and blurred vision. The Veteran is certainly competent to report as to the observable events and symptoms she experiences and their history. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, 6 Vet. App. at 469 (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). In this case, the Board finds that the Veteran's reported history is not credible. The Veteran's STRs show that her neurological functioning was noted to be normal in her December 1995 enlistment examination. The Veteran also denied experiencing frequent or severe headaches in the December 1995 Report of Medical History. A subsequent STR stated that the Veteran was electrocuted by a truck's direct current system after her ratchet fell onto a battery cable. The force threw her left arm away, but it did not hit anything. There was no loss of consciousness. She reported feeling generalized fatigue and a tingling in her left hand. The assessment was status post electrocution. Although the date of this record is unclear, the record noted that an ECG was planned, and additional records show that this test was conducted in May 1998. The STRs do not contain any evidence showing complaints or treatment related to headaches. The Veteran's June 1998 separation examination did not state whether the Veteran's spine or neurological functioning was normal or abnormal. However, while the summary of defects and diagnoses documented mechanical low back pain, no headaches were noted. In addition, the Veteran denied having frequent or severe headaches in her June 1998 Report of Medical History. However, she did report other symptoms such as a history of recurrent back pain; a recent gain or loss of weight; and arthritis, rheumatism, or bursitis. Thus, she was aware of the ability to document problems at that time. After service, the Veteran denied having a headache in a January 2007 VA treatment record. She did complain of nausea and painful bowel movements. She also denied having severe and constant headaches in a subsequent August 2008 VA treatment record. The same record noted that both joint and muscle pain were present. In January 2009, the Veteran complained of tender nodes on the left side of her neck for the past 2 months that became bigger and tender before returning to a smaller and unpainful size. The record stated that her cervical nodes were abnormal. The Veteran reported that she occasionally experienced headaches, especially when the lesions at her neck became bigger. Later in July 2010, the Veteran reported that over the past weekend, she passed out and hit her head after becoming overheated. The Veteran stated that she had experienced migraine headaches since that time. In February 2014, the Veteran reported having a headache that was caused by a dry cough. She had been feeling sick with severe myalgia and shivering. She was assessed to have a urinary tract infection. In VA treatment records dated in January 2015, March 2015, June 2015, and February 2016, the Veteran denied having a headache. In August 2016, the Veteran reported having more frequent headaches in recent weeks with at least two per week. They occurred in the left forehead area, where they had usually occurred over the years. The assessment was headaches. In September 2017, the Veteran again complained of headaches. While no headache was present during the visit, the record stated that they were primarily frontal and parietal. The headaches did not have any associated visual changes, nausea, or vomiting. The record stated that the Veteran described them as tension headaches, but no assessment for this type of headache was documented. Based on the above evidence, the Board finds the Veteran's reports that her headaches have been present since her in-service electrocution, and her assertion that she received treatment for headaches during service, are not credible. Following her electrocution, the Veteran reported symptoms of fatigue and a tingling sensation in her hand, but there was no indication that she experienced headaches. In addition, while the Veteran denied having a history of headaches prior to her separation, she did report a history of several other medical issues. The STRs also reflect that she received in-service treatment for her reported weight gain and recurrent back pain. In light of these reports, the Board finds it unlikely that the Veteran would have denied experiencing a history of headaches if she experienced them during service, especially if she received specific treatment for the complaint. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (citing Fed. R. Evid. 803 (7) for the proposition that "the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded"). The Veteran similarly sought treatment for other problems after service at which times she denied experiencing headaches in 2007 and 2008. Moreover, when the Veteran initially reported headaches in 2009 and 2010, she attributed the symptoms to recently enlarged nodes in her neck and a post-service head injury. These records are inconsistent with her reports of continuous headache symptoms since service. Regarding the Veteran's theory of direct service connection, the Board notes that the June 2017 VA examiner opined that the Veteran's headache disorder was incurred during her active service. The examiner based this opinion on the Veteran's report that her headaches began during service, and her report that she was diagnosed with migraines by a doctor while on active duty. The examiner also pointed to the Veteran's assertion that records of this treatment in Germany had been lost. However, as the Board does not find the Veteran's reported history to be credible, the examiner's opinion based on this reported history is not probative. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (providing that a medical opinion based on an inaccurate factual premise is not probative). Moreover, as there is no record of in-service treatment or complaints related to headaches, any additional opinion would need to rely on the Veteran's less than credible reports of in-service events. Thus, the Board finds that further efforts to obtain a VA medical opinion would be of no service to the Veteran. See Sabonis, 6 Vet. App. at 430. The Board notes that the record has also raised a theory of secondary service connection. In February 2011, a VA treatment record noted the Veteran's report that her sertraline was giving her a headache when taken at a dosage of 50 milligrams. She reported experiencing better results at a lower dosage of 25 milligrams, and she wanted to remain at that dosage. The Board notes that the Veteran is service-connected for posttraumatic stress disorder with depression, and sertraline is an antidepressant. However, during the June 2017 VA examination, the Veteran informed the examiner that she did not recall her previous complaint concerning sertraline. Moreover, she did not feel that her current medication, which included sertraline, was causing her headaches. The examiner also noted that at 100 milligrams, the Veteran's current dosage of sertraline was higher than the dosage in place at the time of the February 2011 record. The examiner concluded that the Veteran's sertraline was not causing her headaches, and it was unrelated to migraines. Thus, the examiner addressed the causation prong of secondary service connection. While the opinion did not specifically discuss aggravation, the Board finds that this concept is implicitly addressed in that examiner's finding that there was no relationship between sertraline and migraines. After considering the opinion as a whole and in the context of the record, the Board finds that the examiner's conclusion provides probative value as it addresses the medical issues in this case and was based on an analysis of the evidence and current medical understanding. See Monzingo v Shinseki, 26 Vet. App. 97, 106 (2012) (providing that an examination is not rendered inadequate where the rationale provided by an examiner did not explicitly lay out the examiner's journey from facts to a conclusion); see also Acevedo v. Shinseki, 25 Vet. App. 289, 294 (2012) (stating that medical reports must be read as a whole and in the context of the evidence of record). Neither the Veteran nor the other evidence of record suggests that any other medications for her service-connected disabilities are related to her migraine headaches. The Board notes that the Veteran's recent assertion that she has tension headaches, as well as her contention that her headache symptoms are the result the in-service electrocution. However, the Board finds that the Veteran is not competent to diagnosis her headache disorder or to determine that her current headache symptoms are the result of the in-service electrocution. These questions are not something that can be determined by mere observation. Nor is this question simple. While the Veteran is competent to report symptoms of headaches, the question of the cause of those symptoms is not an observable fact. It requires clinical testing to assess and diagnose the underlying condition and training to make the appropriate interpretations and conclusions about what the testing demonstrates in conjunction with the symptoms reported to determine the cause. The Veteran in this case has not been shown to possess the requisite medical training, expertise, or credentials needed to render a competent opinion on these questions. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012); Kahana v. Shinseki, 24 Vet. App. 428 (2011). Therefore, the Board finds that the Veteran's statements as to the etiology of her current complaints are not competent evidence of a diagnosis or nexus. In light of the above discussion, the Board finds that the weight of the evidence is against finding that the Veteran's current headache disorder, diagnosed as migraine, including migraine variants, was incurred in active service; or that it was caused or aggravated by medication for her service-connected disabilities. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, that doctrine is not applicable based on these facts. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, service connection is not warranted for a headache disorder, to include as secondary to medication for service-connected disabilities. 38 C.F.R. §§ 3.303, 3.310. Knees Regarding the Veteran's service connection claims for a left and right knee disorder, the Board first notes that she has a current diagnosis of bilateral knee strain. See December 2015 VA examination; March 2017 VA examination. The Veteran has reported that her bilateral knee condition began in 1997 while she was in Germany. See December 2015 VA examination. The Veteran reported that she slipped and fell in Germany on the ice. See March 2017 VA examination. Her back had worsened over the years, and the pain radiated to her knees. The record has also raised the theories that her bilateral knee disorder is secondary to her service-connected lumbar spine disability, left hip disability, and/or right hip disability. A review of the Veteran's STRs reveals that no abnormalities were noted in her lower extremities in the December 1995 enlistment examination. In addition, the Veteran denied having a trick or locked knee in the December 1995 Report of Medical History. On January 23, 1997, an STR stated that the Veteran had slipped on the ice and landed on her back. She complained of low back pain and right thumb pain. There was no loss of consciousness or other complaints. The assessment was right thumb sprain and lumbosacral sprain. On January 28, 1997, the Veteran reported that her back and thumb had greatly improved. There was no ambulatory deficit, and the record specified that only running was permitted during physical training. In April 1997, the Veteran reported that her back felt about the same, and she denied symptoms of numbness or tingling. In June 1997, the Veteran complained of constant low back pain for six months since slipping and falling on the ice in January 1997. The pain was not radiating. The patellar and Achilles deep tendon reflexes were blunted on the right and normal (2+) on the left. The assessment was disc impingement of the L4-5 with coexisting musculoskeletal involvement. In March 1998, an STR indicated that a physical examination of the Veteran's extremities showed that full strength was present bilaterally. In July 1998, the Veteran complained of neck and back pain after falling down the steps the previous day. The assessment was neck strain. No other complaints or diagnoses were noted. The June 1998 separation examination did not state whether the Veteran's lower extremities or spine was normal. Nevertheless, although mechanical low back pain was documented in the summary of defects and diagnoses, no knee problems were noted. The Veteran continued to deny having a trick or locked knee in the associated Report of Medical History. As previously discussed, she did report recurrent back pain; a recent gain or loss of weight; and arthritis, rheumatism, or bursitis. The record stated that she had experienced chronic, mechanical low back pain for one year. It was also noted that she experienced muscle joint pain when getting up. However, she was currently doing well. After service, the Veteran's VA vocational rehabilitation records reflect that she worked in several different positions; including as an assistant manager in a fast food restaurant from September 1998 to July 2000, a correctional officer from August 2000 to March 2002, a loss prevention associate at a retail store from April 2002 to December 2002, a detention officer from January 2003 to June 2003, a billing records technician intern at a military medical center from July 2003 to October 2003, an automated service technician from October 2003 to August 2008, and a supply technician from October 2009 to July 2012. In January 2009, a VA treatment record noted that the Veteran complained of right knee pain, and she reported that the pain was new in its onset. Another VA treatment record from the same date noted that the Veteran's past history was positive for left knee pain. The record stated that she had abnormal joints. However, her ambulation and coordination was normal. A June 2009 VA examination of the lumbar spine also stated that the Veteran's gait was within normal limits. VA treatment records from this month stated that the Veteran was employed at a military fort as a "checker" or cashier. A subsequent July 2009 VA treatment record noted that the Veteran complained of pain in her low back, left hip, and right knee. The record indicated that her knee pain had been present for one month, and it was especially prevalent after a day at work standing up. A study of the left knee was negative. The record stated that the Veteran had been compensating for her hip pain with her right knee, and this practice could be the reason for her knee pain. The assessment indicated that she had osteoarthrosis involving the knee. In August 2010, the Veteran complained of her back hurting, and she indicated that the pain radiated down to her toes. The assessment included osteoarthrosis involving the knee. In August 2011, a VA treatment record reported that the Veteran worked in a warehouse where she intermittently lifted boxes weighing 20 to 50 pounds. During a December 2011 VA examination of the Veteran's lumbar spine, the examiner stated that her posture and gait were both within normal limits. In February 2012, the Veteran presented to a physical therapy appointment at VA with a "side to side" gait, but she was noted to have a normal gait after physical therapy. Subsequent VA treatment records in October 2013 and February 2014 stated that the Veteran's gait was normal. In October 2014, a VA treatment record stated that her gait was antalgic. However, it was described as normal in January 2015 and steady in March 2015. During a June 2015 VA examination of the lumbar spine, the examiner noted that guarding and/or muscle spasm was present in the lumbar spine; but these symptoms did not result in an abnormal gait or contour. A December 2015 VA examination report concerning the Veteran's knees stated that she regularly used a brace. However, her gait was again noted to be normal in another VA examination report related to peripheral neuropathy that was conducted on the same day. In the March 2017 VA examination report for her knees, the examiner also noted that the Veteran was walking with a normal gait and without any braces of canes. No mobility assistance was needed. A subsequent April 2017 VA treatment record noted that her gait continued to be normal. The Board notes that VA treatment records have stated that the Veteran has osteoarthrosis involving the knee. However, the Veteran underwent VA examinations related to her knees in December 2015 and March 2017; and neither examiner diagnosed the Veteran with osteoarthritis or any other form of arthritis. Both examination reports stated that imaging studies had been performed, and the studies did not document degenerative or traumatic arthritis. The March 2017 VA examiner also noted that the July 2009 VA treatment record indicating that the Veteran had osteoarthritis was incorrect in light of the normal x-ray findings from the examination. In addition, the statement from a March 2012 VA treatment record that the Veteran was seen for arthritis and complained of pain in all her joints was related to back arthritis. The examiner also noted that the Veteran complained of pain in her back and hips rather than her knees during that visit. The examiner explained that subsequent VA treatment records that included the osteoarthritis diagnosis had done so based on an automatic pull from her problem list. The Board finds that these examination findings based on imaging studies are more probative than the previous assessments from the treatment records as the record does not reflect that those diagnoses were made in conjunction with similar studies. As the most probative diagnosis of record is bilateral knee strain, the Board finds that the chronic disease presumption does not apply in this case. Regarding the Veteran's theories of service connection, the December 2015 VA examiner opined that it was less likely than not that the Veteran's left or right knee disorder was proximately due to, or the result of, her lumbar spine disability. The examiner noted that back conditions, including degenerative disc disease, involved a different condition and body part that was unrelated to the knees. The examiner also stated that low back pain could radiate to the hips and legs and cause pain. No additional explanation was provided. The Board finds that this opinion provides limited probative value as the examiner's rationale regarding the causation prong of secondary service connection appears to be incomplete. In addition, the examiner did not provide a clear opinion regarding the aggravation prong of secondary service connection in relation to her lumbar spine disability. The opinion also failed address whether the left or right knee disorder was secondary to her hip disabilities. Although the examiner similarly omitted a clear opinion regarding direct service connection, the examiner did note that the Veteran received a 1997 diagnosis of mechanical low back pain and had an in-service complaint of numbness in her bilateral thighs. However, the examiner highlighted that there were no records in the STRs related to the right or left knee. Another opinion was provided by the March 2017 VA examiner. The examiner stated that it was less likely than not that the Veteran's bilateral knee strain was caused by, or the result, of, her active service. The examiner noted that there was no documentation of a knee condition during service or within one year of the Veteran's discharge from service. In addition, the first reports of knee symptoms were noted in VA treatment records dated in January 2009 and July 2009; approximately 11 years after the Veteran's discharge from service. The examiner highlighted the fact that an earlier record from April 2005 was negative for a knee condition. Consequently, the treatment records indicated that the Veteran's knee condition started between 2008 and 2009. The examiner also opined that it was less likely than not that the Veteran's right or left knee condition was proximately due to, the result of, or aggravated beyond its natural progression by her lumbar spine disability, left hip strain, or right hip disability. The examiner noted that the Veteran lumbar spine degenerative disc disease was accompanied by radiculopathy. The examiner explained that the symptoms of the Veteran's lumbar spine degenerative disc disease with radiculopathy included low back pain that radiated to the Veteran's legs. In this regard, a July 2015 VA treatment record reported that the Veteran experienced chronic low back pain that radiated in her lower extremities. This radiation of back pain to the legs was different than intrinsic knee pathology. The Board also notes that the Veteran is already service-connected for her peripheral neuropathy of the bilateral lower extremities. Although the Veteran contended that her intrinsic knee pathology was due to her back disability, the examiner stated that he was unable to find studies in medical literature to support the theory that back arthritis causes knee strain. Medical literature indicated that this absence of a causative relationship was especially applicable in the setting of a normal gait. See Walking Disorders - How Nerve and Joint Injuries Change Gait, The Steadman Clinic (Jan. 8, 2018), https://neckandback.com/conditions/walking-disorders-how-nerve-and-joint-injuries-change-gait/. In addition, the examiner observed that there was no rationale to support the statement from the July 2009 VA treatment record that the Veteran's right knee pain might be caused by the Veteran compensating for her hip with her right knee. The Board also notes that this statement is too speculative to serve as a basis for service connection. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (determining that a medical opinion framed in terms of "may or may not" is speculative and insufficient to support an award of service connection for the cause of death). Moreover, the examiner highlighted that the osteoarthritis diagnosis from the July 2009 record was incorrect in light of current x-ray evidence. The examiner additionally explained that the back and hips were unrelated to the knees, and in a different anatomical location. The examiner also cited to a medical article for the proposition that injuries of the muscles and tendons surrounding the knee, called strains, were caused by acute hyperflexion of the knee, hyperextension of the knee, or overuse. See What are the Types and Causes of Knee Injuries?, eMedicineHealth (Jan. 8, 2018), https://www.emedicinehealth.com/knee_injury/page2_em.htm. The examiner also stated that there was documentation showing that the Veteran's knee injury was caused by a work-related injury. The examiner noted that when he questioned the Veteran about her work history since 1998, the Veteran only reported working as a cashier. However, the examiner found that this report was inconsistent with the statement from the August 2011 VA treatment record that the Veteran lifted boxes weighing 20 to 50 pounds in a warehouse. The examiner also pointed to a February 2013 VA treatment that reported that the Veteran's pain was the result of a work injury in 1997 for which the Veteran was receiving compensation. Thus, the examiner stated that it was more likely than not that her knee condition was due to a work injury and not related to service. The Board notes that it appears that the examiner's conclusions regarding the Veteran's current bilateral knee disorder in relation to a past work injury are based on a misunderstanding of the record. Although the examiner was correct in relaying the report from the August 2011 VA treatment record, the Board notes that the February 2013 VA treatment record that discussed the 1997 work injury was related to the Veteran's complaints of pain in her low back and bilateral lower extremities. There is no specific discussion of the Veteran's knees in this record. The record specifically stated that the lower extremity pain at issue was radiating and shooting pain that was most consistent with an S1 distribution. Thus, it appears that this complaint concerned her service-connected lumbar spine disability and radiculopathy of the bilateral lower extremities rather than her claimed bilateral knee disorder. The record reflects that these disabilities, for which the Veteran is receiving compensation from VA, were related to the work injury of the in-service fall from 1997. For the examiner to conclude that the Veteran's current bilateral knee disorder was also related to this fall would contradict the opinion and complete rationale he provided for direct service connection. It is extremely doubtful that the examiner intended for his conclusion to have this effect. Thus, the Board does not afford probative weight to the examiner's opinion regarding the 1997 work injury discussed in the February 2013 VA treatment record. In addition, the Board does not find that the examiner's misunderstanding of the reports within the February 2013 VA treatment record detracts from the probative value of his other opinions and explanations concerning direct and secondary service connection. It is clear from the rationales that these opinions were based on the examiner's medical expertise and his detailed review of the relevant medical literature as well as the Veteran's medical history. The facts recited in these records were also supported by the other evidence of record. Moreover, the examiner supported his negative opinions with full rationales that were based on several factors apart from the idea that the Veteran had an outside work injury. Thus, the Board does not find that the examiner's misconception about the work injury was a determinative factor in reaching the negative conclusions on direct and secondary service connection. The Board acknowledges the Veteran's report that her bilateral knee symptoms have been present since service, and the Board notes that she is competent to report observable symptoms such as pain. However, the Board does not find that this contention is consistent with the record. As noted above, the Veteran reported several symptoms after her 1997 fall, but there is no indication that she reported knee problems or received treatment for her knees during service. See AZ, 731 F.3d at 1316-17; Buczynski, 24 Vet. App. at 224 (2011); Kahana, 24 Vet. App. at 440. In fact, records after the fall indicated that running was the one activity that she would be able to perform; and that full strength was present in her bilateral lower extremities. In addition, it seems unlikely that the muscle joint pain discussed in the June 1998 Report of Medical History was related to the knees given the fact that she denied experiencing a trick or locked knee. Moreover, as noted by the March 2017 VA examiner, the first complaints related to the knees were not documented until several years after service in 2009. The Board notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor worthy of consideration. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Based on these inconsistencies, the Board finds that the Veteran's statements that she has experienced bilateral knee symptoms since the 1997 fall are not credible. The Board has also considered the Veteran's statements that her current bilateral knee strain is related to the in-service fall, and/or secondary to her service-connected lumbar spine disability, left hip disability, and right hip disability. However, even assuming that the Veteran is competent to opine on these medical matters, the Board finds that the opinions from the VA examiners are more probative, as they were provided by medical professionals with knowledge, training, and expertise; and they were supported by rationales based on such knowledge. The VA examiners reviewed the pertinent evidence and considered the Veteran's reported history and lay statements. Based on the foregoing, the Board finds that the most probative evidence of record supports a finding that the Veteran's current bilateral knee strain was not incurred in service; and it was not caused or aggravated by her service-connected lumbar spine, left hip, or right hip disability. As the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt rule does not apply, and the claim is denied. See Gilbert, 1 Vet. App, at 53. ORDER Entitlement to service connection for a headache disorder, to include as secondary to medication for service-connected disabilities, is denied. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected degenerative disc disease with osteoarthritis of the lumbosacral spine, left hip strain, and/or right hip disability, is denied. Entitlement to service connection for a right knee disorder, to include as secondary to service-connected degenerative disc disease with osteoarthritis of the lumbosacral spine, left hip strain, and/or right hip disability, is denied. ___________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs