Citation Nr: 18151136 Decision Date: 11/19/18 Archive Date: 11/16/18 DOCKET NO. 16-48 105 DATE: November 19, 2018 ORDER New and material evidence has been submitted sufficient to reopen a claim for right knee pain and the petition is granted. New and material evidence has been submitted sufficient to reopen a claim for degenerative joint disease, left knee, and the petition is granted. New and material evidence has been submitted sufficient to reopen a claim for bilateral hip pain and the petition is granted. Entitlement to service connection for a left knee disability, to include degenerative joint disease, left knee, is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left hip disability is denied. Entitlement to service connection for a right hip disability is denied. FINDINGS OF FACT 1. An unappealed January 2009 rating decision denied claims of entitlement to service connection for degenerative joint disease, left knee, right knee pain, and bilateral hip pain. 2. Evidence received since the January 2009 rating decision is new, relevant and probative as to the left knee, right knee, and bilateral hip claims. 3. Clear and unmistakable evidence demonstrates that the appellant’s left knee disability preexisted his active duty and clear and unmistakable evidence demonstrates that the disability was not aggravated beyond its natural progression. 4. The appellant does not have a right knee disability that was incurred in service, is otherwise related to service, or was caused or aggravated by a service-connected disability. 5. The appellant does not have a left hip disability that was incurred in service, is otherwise related to service, or was caused or aggravated by a service-connected disability. 6. The appellant does not have a right hip disability that was incurred in service, is otherwise related to service, or was caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The January 2009 rating decision that denied a claim for degenerative joint disease, left knee, is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1100 (2018). 2. Evidence received since the January 2009 rating decision in relation to the appellant’s claim for entitlement to service connection for degenerative joint disease, left knee, is new and material, and, therefore, the claim is reopened. 38 U.S.C. §§ 5108, 7104 (2012); 38 C.F.R. § 3.156 (2018). 3. The January 2009 rating decision that denied a claim for right knee pain is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1100 (2018). 4. Evidence received since the January 2009 rating decision in relation to the appellant’s claim for entitlement to service connection for right knee pain is new and material, and, therefore, the claim is reopened. 38 U.S.C. §§ 5108, 7104 (2012); 38 C.F.R. § 3.156 (2018). 5. The January 2009 rating decision that denied a claim for bilateral hip pain is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1100 (2018). 6. Evidence received since the January 2009 rating decision in relation to the appellant’s claim for entitlement to service connection for bilateral hip pain is new and material, and, therefore, the claim is reopened. 38 U.S.C. §§ 5108, 7104 (2012); 38 C.F.R. § 3.156 (2018). 7. The criteria for entitlement to service connection for a left knee disability have not been met; left arthroscopically assisted anterior cruciate ligament reconstruction with autograft bond tendon bone graft and medial meniscus repair clearly and unmistakably pre-existed service and clearly and unmistakably was not aggravated therein and arthritis of the left knee was not shown within one year of separation. 38 U.S.C. §§ 1101, 1111, 1110, 1112, 1113, 1131, 1137 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306, 3.307, 3.309 (2018). 8. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2018). 9. The criteria for entitlement to service connection for a left hip disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2018). 10. The criteria for entitlement to service connection for a right hip disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant had active service in the United States Air Force from August 19, 2008, to October 2, 2008. New and Material Evidence 1. Whether new and material evidence sufficient to reopen a claim for right knee pain has been submitted 2. Whether new and material evidence sufficient to reopen a claim for degenerative joint disease, left knee, has been submitted 3. Whether new and material evidence sufficient to reopen a claim for bilateral hip pain has been submitted The appellant claims that his preexisting left knee disability was permanently aggravated as a result of his active service. Specifically, he contends that a permanent aggravation occurred when his foot was stepped on by a fellow service member and he hyperextended his knee. The appellant alleges that his right knee and bilateral hip problems had their onset during service and/or were caused or aggravated by his left knee disability due to overcompensating for the left knee. The appellant has one year from notification of a Regional Officer (RO) decision to initiate an appeal by filing a notice of disagreement (NOD) with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C. § 7105(b) and (c) (2012); 38 C.F.R. §§ 3.160(d), 20.201, and 20.302(a) (2018). In a January 2009 rating decision, the RO found that his preexisting left knee disability was not aggravated beyond a natural progression by his service. As to the right knee and bilateral hip claims, there was no evidence showing that right knee and bilateral hip pain was incurred in or aggravated by active service. The appellant failed to timely appeal or otherwise express disagreement with the rating decision. As such, the January 2009 rating decision ultimately became final. 38 C.F.R. § 20.1103 (2018). As a result, the claims of entitlement to service connection for left knee, right knee, and bilateral hip disabilities may now be considered if new and material evidence has been received since the time of the last final adjudication. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); Evans v. Brown, 9 Vet. App. 273 (1996). Under 38 C.F.R. § 3.156(a), evidence is considered “new” if it was not of record at the time of the last final disallowance of the claim. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Finally, new and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. In determining whether evidence is new and material, the “credibility of the evidence is to be presumed.” Justus v. Principi, 3 Vet. App. 510, 513 (1992). Additionally, when determining whether the appellant has submitted new and material evidence to reopen a claim, consideration must be given to all the evidence since the last final denial of the claim. Evans v. Brown, 9 Vet. App. 273 (1996). Moreover, the appellant need not present evidence as to each element that was a specified basis for the last disallowance, but merely new and material evidence as to at least one of the bases of the prior disallowance. See Shade v. Shinseki, 24 Vet. App. 110 (2010) (holding that it would be illogical to require that a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element). Again, the January 2009 rating decision found that the appellant’s preexisting left knee disability was not aggravated beyond a natural progression by his service. As to the right knee and bilateral hip claims, there was no evidence showing that right knee and bilateral hip pain was incurred in or aggravated by active service. The evidence of record at the time of this RO decision consisted of the appellant’s service treatment records (STRs) and a VA examination in December 2008. The STRs included a July 2004 private record documenting a June 2004 left knee injury as a result of a dirt motorcycle accident. A September 2004 operation report documented a left arthroscopically assisted anterior cruciate ligament reconstruction with autograft bond tendon bone graft and medial meniscus repair. A January 2005 private treatment record indicated that the appellant was being seen 4 months after a left anterior cruciate ligament (ACL) reconstruction and meniscal repair. The appellant had been working and had been in full weight-bearing status for some time. He had been engaging in some light exercise including some mild jogging. There were no complaints of pain or stiffness and the appellant indicated that he was doing very well. An October 2007 Medical Prescreen of Medical History Report included the appellant’s knee surgery to repair the ACL on the left knee, but he had experienced no issues since the injury. A November 2007 letter from a private physician stated that the appellant was last seen in January 2005 having undergone a September 2004 left knee ACL reconstruction with autograft bone tendon graft and medial meniscus repair. At the time he was last seen, the appellant was doing well. A November 2007 Report of Medical Examination included a normal examination of the lower extremities. A November 2007 Report of Medical History noted a history of knee trouble, knee surgery, and used a corrective device. The appellant reported that he had undergone a left anterior cruciate ligament (ACL) repair in 2004, but that it was “perfect” at present. In August 2008, however, the appellant complained of left knee pain that was a 7 out of 10 and had been present for 5 days. While running he passed another trainee, tripped on the trainee’s heel, caught himself, and stepped hard on the left leg. He felt like the knee was “catching.” In September 2008, the appellant had documented knee pain. The appellant discussed his prior ACL surgery and had been medically cleared for service. Left knee pain had started suddenly and it felt like the kneecap was “out of place.” The appellant was recommended for administrative separation and not recommended for re-entry. The comments noted that an MRI showed old findings with no acute changes to the left knee. A later September 2008 record included the appellant’s report of knee pain beginning in week 2 of training without any trauma. The appellant’s November 2008 claim included his allegations that left knee, right knee, and bilateral hip problems began in August 2008. The appellant contended that the right knee and bilateral hip problems were secondary to the left knee disability. The appellant was afforded a VA general medical examination in December 2008. The appellant reported that prior to service he had an ACL tear and meniscus tear that was repaired in 2004. He entered the military in August 2008 and while in service he had someone step on his heel and hyperextended the left knee and reinjured his left knee. Shortly thereafter he was discharged. Since the 2004 injury, his left knee symptoms had been intermittent with remissions. He currently was receiving no treatment. The appellant reported in-service worsening due to the knee giving out frequently and easy fatigability. The appellant had right knee and bilateral hip pain with onset in September 2008. The appellant reported problems due to favoring his left knee affecting his gait and right knee. Following examination, the examiner diagnosed left knee degenerative joint disease and right knee pain and bilateral hip pain with unknown etiology. X-rays of the left knee showed no evidence of fracture or dislocation with mild degenerative narrowing involving the medial joint space compartment. X-rays of the right knee showed minimal narrowing suggestive of early degenerative change in the medial joint space compartment with no evidence of fracture or dislocation. X-rays of the hips were unremarkable. The examiner indicated that the appellant did have a left knee incident that flared the left knee for a period of time. The MRI at the time of injury did not indicate an ongoing injury due to the circumstances that occurred while training. The injury was not aggravated beyond the natural progression by his service. The normal MRI at the time of injury supported the examiner’s conclusion. The right knee and bilateral hip problems had no physical findings that could be associated with the left knee. He had a normal gait and on physical exam and radiological findings the right knee and bilateral hips were within normal limits and should not be associated with the short-term injury of the left knee that was sustained in service. Since the January 2009 rating decision, a February 2012 determination by the Air Force Board for Correction of Military Records (AFBCMR) corrected the appellant’s service records, “to show that on 2 October 2008, he was discharged with disability severance pay and a service characterization of ‘Honorable,’ rather than ‘Uncharacterized’; a Separation Program Designator (SPD) code of ‘JFL’, rather than “JFX’; and, a Narrative Reason for Separation of ‘Physical disability that existed prior to service but was aggravated by the Service, with severance pay’, rather than ‘Personality Disorder.’” A February 2012 Record of Proceedings Air Force Board for Correction of Military Records indicated that, “Attempts to obtain all of his related medical records have thus far been unsuccessful.” In support of his petition to the AFBCMR, the appellant submitted a personal statement and “pertinent medical documentation.” The AFBCMR concluded, “In our view, the applicant’s re-injury to his knee during training constitutes service aggravation of his pre-service condition. Therefore, we believe his narrative reason for separation should be changed to reflect a medically-related discharge and, by regulation, an honorable characterization of his service.” In his May 2012 application to reopen and July 2014 notice of disagreement, the appellant did not provide any specific arguments or new evidence. September 2013 and January 2016 VA treatment records noted full range of motion in all extremities. The appellant was afforded VA examinations in August 2016. The examiner noted a diagnosis of left ACL reconstruction autograft bone tendon bone graft and no right knee diagnosis. The examiner noted the appellant’s pre-service left knee injury and surgery and his re-injury in service while running when another service member stepped on his left foot and both knees were hyperextended. The examiner noted that such an injury to the right knee was not documented and was inconsistent with his reports at the time. Due to favoring the left knee, the appellant began to experience right knee pain. The appellant had x-rays and an MRI of the knees and hips and was unaware of any pathology being found in the testing. The appellant contended that he had been given the wrong discharge code of “erroneous enlistment” and could not apply for disability benefits and ultimately had the code changed to medical honorable. The appellant also claimed that he had been diagnosed with arthritis of the bilateral knees prior to discharge from service and had been told by a physician that it looked like it was getting into the hips at that time. The appellant reported bilateral knee pain since 2008. The examiner noted the absence of hip complaints documented in the service treatment records. X-rays showed normal left knee, right knee, and bilateral hips. Following examination, the examiner concluded that it was less likely than not that the bilateral hip problems were proximately due to or the result of the appellant’s service-connected left knee disability. The rationale noted that the knees were a distinctly separate anatomical location from the hips and the examiner was unable to locate peer-reviewed studies to support the concept that a left knee disability would aggravate the hips. Also, there was no known hip disability that had been diagnosed for either hip. As to the left knee, the left knee disability that clearly and unmistakably existed prior to service was not aggravated beyond its natural progression by an in-service event, injury, or illness. The rationale noted the in-service injury to the left knee, but a contemporaneous MRI did not indicate ongoing issues. Since the MRI showed no acute pathology, the pre-existing left knee disability was not permanently aggravated beyond its natural progression by the appellant’s short time in service. As to the right knee disability, it was not at least as likely as not that the right knee disability was proximately due to or the result of the left knee disability. The rationale indicated that the appellant did not have a current right knee disability. For the same reason, a right knee disability was not proximately due to or the result of the appellant’s left knee disability. In his September 2016 substantive appeal, the appellant argued that the “injury to my [left] knee in 2008 obviously aggravated my knee beyond [its] normal progression. I would not have been able to pass the examination process to enter the service had my knee been impaired. My foot was stepped on during physical training causing my knee to be hyperextended. Medical care had it been properly administered would have corrected my service connected injury. The lack of care from the Air Force has forced me to continue living with a bad knee causing my hips and right knee to be disabilities.” Since the time of the January 2009 rating decision, the appellant has asserted that a physician told him diagnostic testing showed that he had arthritis of the bilateral knees and that the arthritis also looked like the arthritis also was getting into the hips at that time. The basis for the left knee denial was that there was no permanent aggravation of pre-existing left knee disability, but were the appellant to have a new diagnosis of left knee arthritis shown during service that would support his claim that the left knee disability was permanently worsened by service. In addition, the February 2012 AFBCMR determination suggested that there was in-service aggravation of the pre-existing left knee disability. As to the right knee and bilateral hip claims, the appellant’s contentions that he was told during service that he had diagnoses of arthritis of the right knee and that the arthritis was moving into the hips suggests the onset of disabilities in those joints during service. Pursuant to the Court’s holding in Shade and presuming the credibility of the evidence for the sole purpose of determining whether the left knee, right knee, and bilateral hips should be reopened, the Board concludes that the above evidence suggests the possibility that a left knee disability was permanently aggravated by service and that right knee and bilateral hip disabilities had their onset during service. The evidence is new and material. Having reopened the claims, the Board will adjudicate the claims on the merits below. Service Connection Having determined that the claims are reopened, the Board must next determine whether it will be prejudicial to the appellant for the Board to address the merits of the claims. See Bernard v. Brown, 4 Vet. App. 384 (1993). Here, the Board may proceed to adjudicate the merits of the claims of entitlement to service connection without prejudicing the appellant, because the RO reopened and adjudicated the merits of the claims in the prior September 2016 Statement of the Case (SOC). Cf. Bernard, 4 Vet. App. at 394 (where Board proceeds to merits of a claim that the RO has not previously considered, the Board must determine whether such action prejudices the appellant); see also VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). Thus, the Board is addressing a question already considered by the RO. Therefore, there is no risk of prejudice to the appellant. Bernard, 4 Vet. App. at 394. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131 (2012). Certain diseases, to include arthritis, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2018). To establish a right to compensation for a present disability, an appellant 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 between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310. 4. Entitlement to service connection for a left knee disability, to include degenerative joint disease, left knee The appellant contends that he had a left knee disability that pre-existed service and was permanently aggravated therein. Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111 (2012). In order to rebut the presumption of soundness at service entry, there must be clear and unmistakable evidence showing that the disorder preexisted service and there must be clear and unmistakable evidence that the disorder was not aggravated by service. The appellant is not required to show that the disease or injury increased in severity during service before VA’s duty under the second prong of this rebuttal standard attaches. Jordan v. Principi, 17 Vet. App. 261 (2003); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). However, where a preexisting disease or injury is noted on the entrance examination, section 1153 of the statute provides that “[a] preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease.” 38 U.S.C. § 1153 (2012); 38 C.F.R. § 3.306(a) (2018). For appellants who served during a period of war or after December 31, 1946, clear and unmistakable evidence is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service, and clear and unmistakable evidence includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered “aggravation in service” unless the underlying condition itself, as contrasted with mere symptoms, has worsened. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The appellant’s medical examination at the time of his entrance into service did not include any findings or notation of a polio disability or residuals therefrom. As such, the appellant will be presumed to have entered service in sound condition with respect to any polio-related disability. 38 U.S.C. §§ 1111 (2012); see also Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). As noted, however, the presumption can be rebutted by clear and unmistakable evidence. In this case, the evidence of record clearly establishes the appellant’s left arthroscopically assisted anterior cruciate ligament reconstruction with autograft bond tendon bone graft and medial meniscus repair pre-existed his service. Numerous lay and medical reports document the pre-service 2004 left knee injury and surgical repair. In summary, given the consistent lay and medical evidence concluding that left arthroscopically assisted anterior cruciate ligament reconstruction with autograft bond tendon bone graft and medial meniscus repair pre-existed service and the absence of any competent evidence to the contrary, the Board finds that there is clear and unmistakable evidence of record that his left arthroscopically assisted anterior cruciate ligament reconstruction with autograft bond tendon bone graft and medial meniscus repair pre-existed service. See Doran v. Brown, 6 Vet. App. 283, 286 (1994). The Board notes that the presumption of soundness on entrance cannot be overcome simply based on the representations of the appellant of a vague past history during the entrance examination or thereafter. See Miller v. West, 11 Vet. App. 345, 348 (1998) (holding that a veteran’s self-report that he had previously suffered from “depression or excessive worry” prior to service was insufficient to rebut the presumption of soundness as was found in 38 U.S.C.§ 1111); see also Crowe v. Brown, 7 Vet. App. 238, 246 (1995). In this case, however, as discussed above there is both probative clinical and lay evidence of the pre-existing disorder. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (holding that a veteran is competent to report a contemporaneous medical diagnosis). The Board must also determine if there is clear and unmistakable evidence that the disorder was not aggravated during service. In this case, there is clear and unmistakable evidence establishing that the appellant’s left arthroscopically assisted anterior cruciate ligament reconstruction with autograft bond tendon bone graft and medial meniscus repair was clearly and unmistakably not aggravated by service beyond the natural progression of the disease. In this regard, the most credible in-service and post-service medical evidence of record clearly and unmistakably supports the conclusion that the appellant’s pre-existing left arthroscopically assisted anterior cruciate ligament reconstruction with autograft bond tendon bone graft and medial meniscus repair was not permanently aggravated by his service. In that regard, the Board finds the opinions expressed in the multiple VA examination reports of significant probative value. The opinions expressed were based on review of the claims file, in-service and post-service treatment records, and the appellant’s representations. The rationale, however, clearly demonstrates that the examiner found that the appellant had pre-existing left arthroscopically assisted anterior cruciate ligament reconstruction with autograft bond tendon bone graft and medial meniscus repair that was not permanently aggravated by service and that any increase in disability was due to the natural progression of the disability. The rationale relied heavily on the in-service MRI that showed no old findings with no acute changes to the left knee. The Board has considered the appellant’s representations that he was told by a physician during service that x-rays showed left knee arthritis, but such a representation unequivocally is contradicted by the in-service diagnostic testing. Similarly, the Board acknowledges the February 2012 findings of the AFBCMR that the appellant’s pre-existing left knee disability was aggravated by service. Such a finding clearly was based on the appellant’s inaccurate recitation of the facts, rather than a full review of the evidence of record. For example, the February 2012 Record of Proceedings indicated that at the appellant’s medical examination prior to service entrance, “personnel checked him out thoroughly finding his knee in ‘perfect health.’” The November 2007 Report of Medical Examination, however, made no such finding and a contemporaneous Report of Medical History included a notation of the appellant’s report of a 2004 ACL repair that was “’perfect’ now,” which clearly indicates that the “perfect” designation of the knee was the appellant’s and not the medical professional’s assessment. The Record of Proceedings also noted that an in-service MRI showed no new injury, but failed to reconcile this finding with its ultimate conclusion that the left knee disability was aggravated by service. Finally, the Record of Proceedings conceded that not all medical records had been reviewed in reaching the determination. In light of the foregoing, the Board affords the AFBCMR findings extremely limited probative weight and finds that they are overwhelmingly outweighed by the VA medical opinions of record. As noted above, the underlying disorder, as opposed to the symptoms, must be shown to have worsened in order to find aggravation. In this case, there is no objective evidence of a permanent aggravation in service, as evidenced by the contemporaneous medical evidence (including diagnostic testing results). The appellant clearly injured the left knee in service, but there was no permanent worsening of the overall left knee disability as a result of the in-service incident. Thus, the evidence of record supports the conclusion that a permanent aggravation of a pre-existing left arthroscopically assisted anterior cruciate ligament reconstruction with autograft bond tendon bone graft and medial meniscus repair did not occur. See Jensen, 4 Vet. App. at 306-07; Green, 1 Vet. App. at 323; Hunt, 1 Vet. App. at 297. Indeed, the only evidence that the appellant’s left arthroscopically assisted anterior cruciate ligament reconstruction with autograft bond tendon bone graft and medial meniscus repair was permanently aggravated by service is his own current lay assertions and the February 2012 AFBCMR based primarily or exclusively on the appellant’s lay assertions. The Board finds the appellant’s lay assertions to be of lessened probative value, given his acknowledgment during VA examination that his left knee problems have been intermittent in nature over the years. In any case, the Board finds the in-service and post-service medical evidence overwhelms the appellant’s lay contentions as to whether a permanent worsening of his left knee disability occurred in service. In summary, the credible and probative evidence of record clearly and unmistakably establishes that the appellant’s left arthroscopically assisted anterior cruciate ligament reconstruction with autograft bond tendon bone graft and medial meniscus repair pre-existed service and was not aggravated beyond its natural progression by service. To the extent that the appellant has any other left knee disability there is no competent evidence linking any such disability to the appellant’s service. 5. Entitlement to service connection for a right knee disability 6. Entitlement to service connection for a left hip disability 7. Entitlement to service connection for a right hip disability As noted above, the appellant contends that he has right knee, right hip, and left hip disabilities that were incurred in service, are otherwise related to service, and/or were caused or aggravated by his left knee disability. The question for the Board is whether the appellant has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the appellant does not have a current diagnosis of right knee, right hip, or left hip disabilities and has not had one at any time during the pendency of the claims or recent to the filing of the claims. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). Multiple VA examiners have considered whether the appellant’s symptoms warrant a diagnosis of right knee, right hip, and/or left hip disabilities and have found that the appellant did not have a specific diagnosis with respect to the right knee, left hip, or right hip other than pain of unknown etiology. The Board recognizes that pain alone can constitute a disability under the Court’s holding in Saunders v. Wilkie, 886 F.3d 1356 (Vet. App. 2018) where pain alone results in functional impairment. In this case, however, multiple VA examiners have found no evidence of pain on ranges of motion of the right knee, right hip, and left hip (including following repetitive motion) or other objective evidence of functional impairment. Subjective pain alone has not been found to be sufficient to constitute a disability and in this case the medical evidence (including diagnostic testing) has failed to show any objective limitation due to the appellant’s reported right knee, right hip, and left hip symptoms. Even were the Board to accept that the appellant’s subjective reports of functional limitation constituted right knee, right hip, and/or left hip disabilities for VA compensation purposes, the evidence of record fails to establish that such problems were incurred in service, are otherwise related to service, or were caused or aggravated by a service-connected disability. The appellant’s primary argument is that her right knee and bilateral hip problems are due to overcompensating for left knee problems. As discussed above, entitlement to service connection for a left knee disability is not warranted and, as such, entitlement to service connection for disabilities caused or aggravated by such disability would not warrant service connection. (The Board notes in any case that the medical evidence of record fails to support the appellant’s lay report of a connection between the right knee, right hip, and left hip problems and his long-standing left knee disability.) As to whether such disabilities had their onset in service or are otherwise related to service, the Board has considered the appellant’s current representations that he hyperextended his right knee at the time of his August 2008 in-service left knee injury and that he was told by a physician during service that x-rays showed right knee arthritis and the beginnings of bilateral hip arthritis. The Board finds such representations extremely problematic in light of the contemporaneous medical evidence, at which time the appellant discussed only left knee problems associated with his August 2008 injury and failed to report any contemporaneous problems with the right knee. The Board finds it reasonable to conclude that had the appellant been experiencing ongoing right knee problems at the same time as left knee problems that he would have reported such problems at the time. Moreover, the appellant has been inconsistent as to the precise circumstances surrounding his August 2008 injury. During service, the appellant stated only that while running he passed another trainee, tripped on the trainee’s heel, caught himself, and stepped hard on the left leg. During his first VA examination he made a similar report. It was only at the time of his second VA examination that he asserted that he hyperextended both knees at the time of the August 2008 running injury. In light of the foregoing, the Board finds his representations as to a right knee injury during service to be less than credible. Credibility is an adjudicative and not a medical determination. The Board has “the authority to discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence.” Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In this case, the “inherent characteristics” of the appellant’s current statements as to the incurrence of an in-service right knee injury are inconsistent with the objective medical record. Similarly, as the service treatment records and the post-service records for many years do not include any lay or medical evidence of in-service x-rays of the right knee, right hip, or left hip (which would be consistent with the appellant’s failure to report any such problems during service) the Board finds the appellant’s representations as to a physician telling him that he had right knee arthritis and the beginnings of bilateral hip arthritis to be less than credible. The Board acknowledges the case of Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), wherein the Court held that the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. In this case, however, the appellant failed to advance such a contention until his claim had been denied on multiple occasions by the RO. Had he received an in-service diagnosis of arthritis of the claimed joints, the Board finds it reasonable to conclude that the appellant would have made such a contention prior to his claim being denied on multiple occasions. See Caluza v. Brown, 7 Vet. App. 498 (1995) (holding that in weighing an applicant’s credibility, the Board may consider any evidence of interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, and desire for monetary gain); see also Pond v. West, 12 Vet. App. 341 (1999) (noting that although Board must take into consideration a veteran’s statements, it may consider whether self-interest may be a factor in making such statements). The representations as to in-service diagnoses are inconsistent with the in-service evidence and multiple years of post-service evidence. Finally, the Board has considered the appellant’s general assertions that his current right knee, right hip, and left hip problems had their onset in service or are otherwise related to service. In that regard, the Board recognizes that lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Given the appellant’s lack of demonstrated medical expertise, the complexity of diagnosing right knee, right hip, and left hip disabilities, linking the etiology such disabilities to specific incidents in service, and the appellant’s problematic statements regarding the actual events in service and thereafter that form the basis for his opinions, the Board concludes that in this case his statements regarding any such diagnoses or link are not competent evidence. As such, the Board affords significantly greater probative weight to the conclusions of the VA examiners and other medical evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). In light of the foregoing, the Board finds that the preponderance of the evidence is against the claims, and the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). The appeals must therefore be denied. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel