Citation Nr: 1808951 Decision Date: 02/13/18 Archive Date: 02/23/18 DOCKET NO. 13-02 394 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for a left knee condition. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD R. Kipper, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1986 to August 1987, February 2005 to June 2005, and April 2008 to July 2008, with additional with periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) in the Air National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in December 2010 by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In October 2015, the Veteran testified during a hearing before the undersigned Veterans Law Judge (VLJ) at the RO; a transcript of that hearing is of record. In December 2015, the Board remanded this matter for further development. FINDINGS OF FACT 1. The Veteran entered service with a pre-existing left knee condition manifested by medial meniscectomy with residual scars. 2. The Veteran's pre-existing left knee condition manifested by medial meniscectomy with residual scars was not aggravated by active service or any period of ACDUTRA or INACDUTRA. 3. Left knee arthritis is related to the pre-existing left knee condition and was not otherwise incurred in or aggravated by service. CONCLUSION OF LAW The criteria for establishing service connection for a left knee condition have not been met. 38 U.S.C. §§ 1112, 1113, 1131, 1153 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). In the present case, VA's duty to notify was satisfied by way of an August 2010 letter to the Veteran. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The record reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. The Veteran has not identified any outstanding evidence, to include any other medical records, which could be obtained to substantiate his appeal. Additionally, the Board finds that there has been substantial compliance with its previous remand directives, to include obtaining outstanding records, providing the Veteran with a VA examination, and obtaining an etiology opinion. In light of the foregoing, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C. § 5103(a), § 5103A, or 38 C.F.R. § 3.159, and that all necessary development has been accomplished. Therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Service Connection The Veteran contends that his current left knee condition was caused or aggravated by service. A. Legal Criteria Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. 1110, 1131 (2012); 38 C.F.R. 3.303 (a) (2017). The term active military service includes active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101 (24). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d). A veteran is presumed to be in sound condition, except for defects, infirmities, or disorders noted when examined, accepted, and enrolled for service, or when clear and unmistakable evidence establishes that an injury or disease existed prior to service and was not aggravated by service. 38 U.S.C. § 1111. The burden is on the Government to rebut the presumption of sound condition upon induction by clear and unmistakable evidence showing that the disorder existed prior to service and was not aggravated by service. See VAOPGCPREC 3-2003 (holding in part, that 38 C.F.R. § 3.304(b) is inconsistent with 38 U.S.C. § 1111 to the extent it states that the presumption of sound condition may be rebutted solely by clear and unmistakable evidence that a disease or injury existed prior to service). "[I]f a preexisting disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); see 38 U.S.C. § 1153; 38 C.F.R. § 3.306. In such claims, the Veteran has the burden of showing that there was an increase in disability during service to establish the presumption of aggravation. If the veteran meets his burden of demonstrating an increase in disability during service, the preexisting condition is presumed to have been aggravated in service, and the burden is on the Secretary to rebut the presumption. Horn v. Shinseki, 25 Vet. App. 231, 234 (2012); 38 U.S.C. § 1153; 38 C.F.R. § 3.306. To rebut the presumption, the Secretary must show, by clear and unmistakable evidence, that the worsening of the preexisting condition was due to the natural progress of the condition. Horn, 25 Vet. App. at 235 n.6. Temporary or intermittent flare-ups of a preexisting injury or disease, however, 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). Under 38 U.S.C. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). In deciding the Veteran's claim, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event; or, whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. B. Factual Background Private treatment records associated with the Veteran's service treatment records show that the Veteran underwent a left medial meniscectomy to repair a torn medial meniscus in March 1980. During the Veteran's July 1986 enlistment examination, the Veteran indicated that he had knee surgery to remove his left medial meniscus in 1980. The Veteran's lower extremities were evaluated as clinically normal; however, a left knee surgical scar was noted. The examiner also noted "1980--knee surgery, left medial meniscus removed...see attached report." During an October 1986 enlistment examination, the Veteran reported a left knee medial meniscectomy in 1979, secondary to a football injury. A note entitled "Enlistment Physical Exam" reflects negative findings except, in pertinent part, an 8 centimeter medial meniscectomy scar on the left knee, no instability, and full range of motion and strength. A February 1987 service treatment record shows that the Veteran was treated for pain radiating from the right testes to the hip and gross hematuria. In April 1987, he was treated for kidney stones and a bone island of the right S-I joint. Annual medical certificates dated in July 1987, February 1988, December 1988, and November 1989 show that the Veteran denied that his medical condition had undergone a change during the past year. During an April 1991 periodic examination, the Veteran reported a history of left knee surgery when he was 18 years old. His lower extremities were evaluated as clinically abnormal due to a left knee surgical scar. In the summary of defects section of the report, "previous knee surgery" was noted. Annual medical certificates dated in January 1992 and October 1992 show that the Veteran denied that his medical condition had undergone a change during the past year. Annual medical certificates dated in September 1993, September 1994, and August 1995 show that the Veteran denied having any current medical problems. During a June 1996 periodic examination, the Veteran reported a history of left knee, post trauma arthritis secondary to an operation at age 18 with no current limitations. His lower extremities were evaluated as clinically normal, other than a left knee scar. Annual medical certificates dated in December 1997 and November 1998 show that the Veteran denied having any current medical problems. A July 2000 private treatment record written by Dr. J.R.M. shows that the Veteran reported undergoing a total medial meniscectomy in 1980 that was related to previous trauma. He reported relatively good function of the left knee for the past several years, but increasing left knee symptoms over the past month. The impression was "early degenerative joint disease secondary to previous meniscectomy and trauma." Dr. J.R.M. indicated that "his symptoms are most likely related to a progressive degenerative disease related to previous trauma." Later that month he underwent arthroscopy of the left knee. During a March 2001 periodical examination, the Veteran reported that he had left knee surgery in 2000 that "healed well-can run again." His lower extremities were evaluated as clinically normal. In October 2004, the Veteran reported having pre-cancerous moles removed, and he denied any other significant medical or surgical history since his last examination in October 2003. A January 2005 private treatment note written by Dr. J.R.M. shows that the Veteran was "going active duty soon" and needed clearance from orthopedics that he could do the activities required of him. He reported his knee had been doing well since his surgery in July 2000. The Veteran reported ongoing low grade pain that "does not hinder him in any way." An x-ray showed mild joint space narrowing to the medial aspect of the left knee, and the impression was "previous osteoarthritis medial compartment left knee-mild." Dr. J.R.M. noted that the Veteran's "left knee is an ongoing problem, but it is very minimally disabling and at this point he really requires no significant treatment for it." Dr. J.R.M. also indicated that the Veteran "should and is capable of return to full active duty military without restriction. He may participate in any physical training exercise as necessary for active duty military." During a February 2005 pre-deployment health assessment, the Veteran reported that his health was "excellent," and he denied having any medical problems. During a May 2005 post-deployment health assessment, the Veteran reported that his health was "excellent," and he indicated that his health stayed about the same or got better during his deployment. He reported developing a runny nose and fever during his deployment, but he denied all other symptoms, including swollen, stiff, or painful joints. He also denied having any medical problems that development during the deployment. In November 2005, the Veteran denied any significant medical or surgical history since his last examination in October 2004. An August 2006 service treatment record shows that the Veteran's physical profile was changed from '1' to '2' for lower extremities due to previous left knee surgery and that the Veteran was able to ride his bike at home and could do all physical training evaluation except for run. In October 2006, the Veteran reported continued monitoring for lymphoma and arthritis, and he any other significant medical or surgical history since his last examination in November 2005. A December 2006 private medical history form shows that the Veteran reported pain in both hands, his left elbow, and his left shoulder. During a May 2007 post-deployment health re-assessment, the Veteran rated his health over the past month as "very good," and he indicated that his health was "about the same" as it was before he deployed. In October 2007, the Veteran reported having had a cardiac stress test during an annual physical, and he denied any other significant medical or surgical history since his last examination in October 2006. During an April 2008 pre-deployment health assessment, the Veteran reported that his health was "excellent," and he denied having any medical problems. During a July 2008 post-deployment health assessment, the Veteran rated his health over the past month as "very good," and he indicated that his health was "about the same" as it was before he deployed. He also indicated that he was not wounded, injured, assaulted, or otherwise physically hurt during his deployment. During a July 2008 report of medical assessment, the Veteran reported that he was treated for kidney stones since his last medical assessment and that he was currently taking an antibiotic for an ear infection. He denied suffering from any injury or illness while he was on active duty for which he did not seek medical care. In November 2008, the Veteran reported having a kidney stone in May 2008, and he denied any other significant medical or surgical history since his last examination in October 2007. During a February 2009 post-deployment health re-assessment, the Veteran rated his health over the past month as "excellent," and he indicated that his health was "about the same" as it was before he deployed. He also indicated that he was not wounded, injured, assaulted, or otherwise physically hurt during his deployment. He reported that the only health concern or condition that he felt was related to his deployment was kidney stones. In September 2009, the Veteran reported being diagnosed with sleep apnea and having a basal cancer removed from his back since his last examination dated in November 2008. He also indicated that no other significant medical or surgical history had occurred since his last examination. An October 2009 VA treatment record shows that the Veteran sought to establish care. He reported mild arthritic pain in his hands, left hip, and left knee. He also reported in-theater medical conditions of "chest congestion Bagdad" and kidney stones. A December 2009 private orthopedic note written by Dr. J.R.M. shows that the Veteran requested a reassessment of his left knee to "submit a file for evaluation" for VA benefits. Dr. J.R.M. noted that he had not seen the Veteran since January 2005 when the Veteran was "active duty military," at which time the Veteran had "known osteoarthritis to the medial compartment of his left knee." The Veteran reported generalized aches and pain in both knees, but in particular, the left. X-rays of the left knee showed joint space narrowing and demonstrated "no significant interval change and appear[ed] to be identical to the x-ray dated January 8, 2005." Dr. J.R.M. indicated that the Veteran had seven percent impairment of the left knee and opined that "this impairment is directly related to the patient's military service connected injury to his left knee." In January 2010, the Veteran was found to be medically disqualified for worldwide duty due to a diagnosis of sleep apnea. The Veteran retired from the Air Force Reserves in April 2010. In a May 2011 statement, the Veteran indicated that he had surgery on his left knee before going into service and that after going into service, his left knee condition was aggravated and is worse than when he entered service. He also indicated that he had to have additional surgery when he was in service. In a January 2013 statement, the Veteran reported that a left knee injury occurred while in Iraq in 2005. He also asserted that although he did have a high school injury, the presumption of soundness applies in his case because he was accepted for military service. During the October 2015 Board hearing, the Veteran testified that he was under a physician's care for his left knee for his "entire career" due to running, training, and the PT requirements. He also testified that he injured his knee "pretty severely" in Iraq in 2005 when he stepped out of the back of his truck and his left knee popped. He testified that his knee was swollen to the size of a grapefruit for two weeks, but that he did not seek treatment during his deployment. He also testified that he did not report the injury when he returned from deployment because he had to "soldier on" and because "an injury like that can be career ending." A December 2015 private treatment note written by Dr. J.R.M. shows that the Veteran requested an evaluation of his left knee. Dr. J.R.M. indicated that the Veteran had about a seven percent impairment of the left knee as it relates to osteoarthritis and joint space narrowing and opined that the Veteran's left knee would not be as arthritic were it not for "the activities of a soldier as well as other minor injuries he sustained as a solider combined with just activities of being a soldier." The Veteran was afforded a VA examination in March 2016. The examiner noted diagnoses of left knee meniscal tear in February 1980 and left knee joint osteoarthritis in July 2000. After an examination, the examiner indicated that the Veteran's current left knee condition was DJD/osteoarthritis. The examiner opined that it was clear and unmistakable that the Veteran had a pre-existing left knee condition, namely torn medial meniscus and surgery, on enlistment into the military because such is noted on his enlistment history and physical and on multiple other records over the course of his service career. The examiner also opined that the Veteran's current left knee DJD/osteoarthritis is more likely as not directly related to his pre-service left knee injury and surgery because medical literature indicated that the natural history of such a knee condition is more likely as not DJD. The examiner further opined that it is less likely as not that the Veteran's pre-existing left knee condition was aggravated beyond its natural expected progression by his active duty training and deployment activities. The examiner indicated that the "degree of stress and wear and tear on the Left knee is the sum total that has been present since his initial injury in 1980." The examiner also noted that service treatment records document no knee injuries or complaints. C. Analysis As an initial matter, the Board notes that the Veteran has been diagnosed with left knee osteoarthritis. As such, the Board finds the current disability element is established. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For the Veteran's first period of active service, from October 1986 to August 1987, the Board observes that a left knee condition manifested by medial meniscectomy with residual scars was noted on enlistment examinations in July 1986 and October 1986. Although the entrance examinations concluded that the Veteran was fit for duty, this does not diminish the fact that the Veteran's pre-existing left knee condition was documented, or noted. Therefore, the presumption of soundness does not apply as to this condition. As noted above, a preexisting injury or disease will be considered to have been aggravated by active 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; 38 C.F.R. § 3.306 (b). The evidence with respect to the Veteran's first period of active service is negative for any indication of a worsening or increase in disability of the pre-existing left knee condition. In this regard, the Veteran sought treatment for kidney stones and a hip condition, but he did not report any left knee symptoms. Moreover, annual medical certificates dated in July 1987 (while the Veteran was still on active duty), February 1988, December 1988, and November 1989 show that the Veteran denied that his medical condition had undergone a change during the past year. Accordingly, the Board finds that there was no increase in disability during the Veteran's first period of active service so as to warrant a presumption of aggravation. As to left knee arthritis, which was diagnosed in July 2000 (i.e. after the first period of active service, but before the second period of active service), the Board concludes that the preponderance of the evidence is against a finding that arthritis had its onset during the first period of active duty service, that arthritis manifested within one year following the Veteran's discharge from this service, or that it is otherwise due to this period of service or to any subsequent periods of ACDUTRA or INACDUTRA. Rather, the evidence reflects that left knee arthritis diagnosed in July 2000 is a natural progression of the pre-existing left knee condition. In this regard, when Dr. J.R.M. diagnosed the Veteran with left knee degenerative joint disease in July 2000, he clearly indicated that it was secondary to previous meniscectomy and trauma, and he further noted that the Veteran's symptoms were "most likely related to a progressive degenerative disease related to previous trauma." Similarly, the March 2016 VA examiner opined that the Veteran's left knee DJD/osteoarthritis was more likely as not directly related to his pre-service left knee injury and surgery because the natural history of such a knee condition is more likely as not DJD. The VA examiner essentially found that the degenerative joint disease is a natural progression of the pre-existing left knee condition. The clinical evidence of record also fails to show that the Veteran manifested arthritis to a degree of 10 percent within one year following his active duty service discharge in 1987. In this regard, the record reflects no complaints related to left knee arthritis until July 2000, when the Veteran reported a one-month history of symptoms. As such, presumptive service connection as a chronic disease, to include based on continuity of symptomatology, is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. For the Veteran's second period of active service, from February 2005 to June 2005, the Board finds that the presumption of soundness does not apply. As noted above, the presumption of soundness applies when the Veteran is "examined, accepted and enrolled for service." 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). Here, however, the Veteran was in the Air National Guard beginning in August 1987 (i.e., after his first period of active service) and was called to active duty in February 2005. The record does not contain a contemporaneous examination relevant to this period of active service. Thus, the Board finds that the Veteran entered this period of service with a pre-existing left knee condition manifested by medial meniscectomy with residual scars. Moreover, the record reflects that the Veteran also entered this period of service with pre-existing left knee osteoarthritis, which was diagnosed in July 2000. Thus, the Veteran may only bring a claim for service-connected aggravation of these conditions. The Veteran has the burden of showing that there was an increase in disability during service to establish the presumption of aggravation. The evidence with respect to the Veteran's second period of active service is negative for any indication of a worsening of the pre-existing left knee condition. In this regard, private treatment records dated in January 2005, just prior to the Veteran's entrance onto active duty, show that the Veteran's left knee osteoarthritis was "mild" and "very minimally disabling." During a May 2005 post-deployment health assessment, the Veteran reported that his health was "excellent," and he indicated that his health stayed about the same or got better during his deployment. He reported developing a runny nose and fever during his deployment, but he denied all other symptoms, including swollen, stiff, or painful joints. He also denied having any medical problems that development during the deployment. Thereafter, the Veteran denied any significant medical history in November 2005, and during a May 2007 post-deployment health re-assessment, the Veteran indicated that his health was "about the same" as it was before he deployed in February 2005. The Board acknowledges the Veteran's assertions that he injured his left knee during this period of service when he twisted it stepping out of a truck. The Veteran is competent to report such an occurrence. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board also acknowledges the Veteran's contention that he did not seek treatment in service due to mission requirements. It is noted that temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Crowe v. Brown, 7 Vet. App. at 247-48; Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Likewise, evidence of a Veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. at 320. Thus, "a lasting worsening of the condition" - that is, a worsening that existed not only at the time of separation but one that still exists currently is required. Routen v. Brown, 10 Vet. App. 183, 189 (1997); Verdon v. Brown, 8 Vet. App. 529, 538 (1996). Here, even accepting that the Veteran twisted his left knee during his second period of service, the record does not reflect that the underlying disability underwent an increase in severity during this period of service. In this regard, during a May 2005 post-deployment health assessment, the Veteran reported that his health was "excellent," and he indicated that his health stayed about the same or got better during his deployment. He reported developing a runny nose and fever during his deployment, but he denied all other symptoms, including swollen, stiff, or painful joints. He also denied having any medical problems that developed during the deployment. Similarly, in November 2005, after his period of active service, the Veteran denied any significant medical or surgical history since his last examination in October 2004, and, during a May 2007 post-deployment health re-assessment, the Veteran rated his health over the past month as "very good," and he indicated that his health was "about the same" as it was before he deployed. Thus, the contemporaneous records show that the pre-existing left knee condition was not permanently aggravated during this four-month period of active duty as the Veteran denied relevant symptoms right before discharge, and he continued to deny symptoms five months after discharge and two years after discharge. Significantly, x-rays of the left knee dated in December 2009 demonstrated "no significant interval change and appear[ed] to be identical to the x-ray dated January 8, 2005." Thus, there is affirmative medical evidence showing that the Veteran's underlying left knee condition did not undergo an increase in severity during his second period of active service. For the Veteran's final period of active service, from April 2008 to July 2008, the Board finds that the presumption of soundness does not apply. As with the Veteran's second period of active service, the Veteran was called to active duty in April 2008, and the record does not contain a contemporaneous examination relevant to this period of active service. Thus, the Veteran may only bring a claim for service-connected aggravation of his pre-existing left knee condition. The evidence with respect to the Veteran's final period of active service is negative for any indication of a worsening of the pre-existing left knee condition. The Veteran has not alleged a worsening of the left knee condition during this period of service (versus the second period of active duty). Moreover, the record does not reflect that the disability underwent an increase in severity during this period of service. During a July 2008 post-deployment health assessment, the Veteran rated his health over the past month as "very good," and he indicated that his health was "about the same" as it was before he deployed. He also indicated that he was not wounded, injured, assaulted, or otherwise physically hurt during his deployment. During a July 2008 report of medical assessment, the Veteran reported that he was treated for kidney stones since his last medical assessment and that he was currently taking an antibiotic for an ear infection. He denied suffering from any injury or illness while he was on active duty for which he did not seek medical care. In November 2008, the Veteran reported having a kidney stone in May 2008, and he denied any other significant medical or surgical history since his last examination in October 2007. During a February 2009 post-deployment health re-assessment, the Veteran rated his health over the past month as "excellent," and he indicated that his health was "about the same" as it was before he deployed. He also indicated that he was not wounded, injured, assaulted, or otherwise physically hurt during his deployment. He reported that the only health concern or condition that he felt was related to his deployment was kidney stones. The Board has also considered the Veteran's general contention that the training and fitness requirements he was obligated to engage in and comply with during various periods of service, including ACDTURA and INACDTURA, aggravated his pre-existing left knee condition beyond its natural progression. Specifically, during the October 2015 Board hearing, the Veteran testified that he was under a physician's care for his left knee for his "entire career" due to running, training, and the PT requirements. The Board finds probative the March 2016 VA opinion. The examiner provided rationale in support of the opinion, with clear conclusions, supporting data, and reasoned medical explanations. See Nieves-Rodriguez, supra; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Read as a whole, the VA examiner found that there was no credible evidence that the Veteran's pre-existing left knee disability underwent a chronic worsening in service (i.e., increased in disability). See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (providing that the adequacy of medical reports must be based upon a reading of the report as a whole). Furthermore, the conclusions are consistent with the evidence of record, which shows no increase in the level of severity of the Veteran's left knee condition over the course of his career. In this regard, annual medical certificates dated in July 1987, February 1988, December 1988, November 1989, January 1992, October 1992, September 1993, September 1994, August 1995, December 1997, and November 1998 show that the Veteran denied any significant medical history or changes, and during periodic examinations in April 1991 and June 1996, the Veteran's previous left knee surgery was noted, and his lower extremities were evaluated as clinically normal. After the Veteran's left knee surgery in 2000, he reported during a March 2001 periodical examination that he had left knee surgery in 2000 that "healed well-can run again." His lower extremities were evaluated as clinically normal. Thereafter, there was no evidence of increased left knee symptomatology on annual medical certificates dated in October 2004, November 2005, October 2006, October 2007, November 2008, and September 2009. Moreover, as noted above, in January 2005, the Veteran reported to Dr. J.R.M. that his left knee condition did not hinder him in any way, and Dr. J.R.M. noted that the Veteran's "left knee is an ongoing problem, but it is very minimally disabling and at this point he really requires no significant treatment for it." The Veteran acknowledges the December 2009 and December 2015 opinions of Dr. J.R.M. In December 2009, Dr. J.R.M. noted that he had not seen the Veteran since January 2005 when the Veteran was "active duty military," at which time the Veteran had "known osteoarthritis to the medial compartment of his left knee." Dr. J.R.M. indicated that the Veteran had seven percent impairment of the left knee and opined that "this impairment is directly related to the patient's military service connected injury to his left knee." The Board finds this opinion to be of little probative value as it is wholly unsupported by rationale and based on an inaccurate factual premise, namely the Veteran's assertions that his symptoms manifested during active service. Reonal v. Brown, 5 Vet. App. 458 (1993) (VA is not required to accept the credibility of a medical opinion which is based upon an inaccurate factual history); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If [an] opinion is based on an inaccurate factual premise, then it is correct to discount it entirely.") In December 2015, Dr. J.R.M. indicated that the Veteran had about a seven percent impairment of the left knee as it relates to osteoarthritis and joint space narrowing and opined that the Veteran's left knee would not be as arthritic were it not for "the activities of a soldier as well as other minor injuries he sustained as a solider combined with just activities of being a soldier." The Board finds that this opinion is not probative as it is completely inconsistent with the other evidence of record, to include Dr. J.R.M.'s previous treatment notes showing no increase in the Veteran's left knee disability. In this regard, when Dr. J.R.M. first examined the Veteran in July 2000, he specifically noted that the Veteran's left knee DJD was most likely related to a progressive degenerative disease related to the 1980 meniscectomy and trauma. When Dr. J.R.M. examined the Veteran in January 2005, he noted mild left knee osteoarthritis, and he indicated that it was minimally disabling. He also indicated that the Veteran "should and is capable of return to full active duty military without restriction. He may participate in any physical training exercise as necessary for active duty military." Most significantly, when Dr. J.R.M. examined the Veteran in December 2009, less than a year before the Veteran retired from National Guard service, x-rays of the left knee demonstrated "no significant interval change and appear[ed] to be identical to the x-ray dated January 8, 2005." This evidence shows that over a nine year period during which the Veteran was performing the activities of a soldier, there was no significant change in the Veteran's left knee condition, which is inconsistent with the December 2015 opinion that the Veteran's military service aggravated the Veteran's left knee arthritis beyond its natural progression. Therefore, these letters are, at best, minimally probative, and are outweighed by the VA opinion discussed above. The Board acknowledges the Veteran's assertions that his left knee condition was aggravated by his military service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology or aggravation of a knee condition falls outside the realm of common knowledge of a lay person. For all the reasons described above, the Board finds that the claim of entitlement to service connection for a left knee condition must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for a left knee condition is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs