Citation Nr: 20031277 Decision Date: 05/05/20 Archive Date: 05/05/20 DOCKET NO. 09-21 961 DATE: May 5, 2020 ORDER Entitlement to service connection for bilateral knee disability, to include secondary to service-connected constipation, is denied. Entitlement to service connection for right hand/wrist carpal tunnel syndrome (CTS), is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran sustained an in-service injury or disease upon which service connection for a bilateral knee disability can be based. The preponderance of the evidence is also against a finding that the Veteran’s bilateral knee disability is otherwise causally related to service, to include his service-connected constipation. Any additional development of the claim was precluded due to the Veteran’s refusal to report to a scheduled VA examination without good cause shown. 2. The Veteran’s right wrist CTS did not have its onset in service, did not manifest to a compensable degree within one year of discharge, and is not otherwise causally related to the Veteran’s service. Any additional development of the claim was precluded due to the Veteran’s refusal to report to a scheduled VA examination without good cause shown. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.309, 3.655, 4.9. 2. The criteria for entitlement to service connection for right wrist CTS have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.309, 3.655, 4.9. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from February to April 1977. This matter is before the Board of Veterans’ Appeals (the Board) on appeal from a September 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. The rating decision denied service connection for a bilateral knee disability and right-hand CTS because evidence received was not new or material. (The claims were originally filed in August 2001 and denied in an unappealed May 2002 rating decision.) In September 2012, the Board issued a decision reopening the claims and remanding them for further development. Most recently, the Board issued a remand in August 2014 for additional development. The Agency of Original Jurisdiction (AOJ) substantially complied with the remand orders. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or, if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303 (b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for a bilateral knee disability. The Veteran contends that his current bilateral knee disability is related to his service. He alleges that while in service, he slipped and fell on ice and sustained injuries to his hands, back, and knees. He alleges that he has had knee pain since then which now has caused him to have to use a wheelchair. The Veteran’s service treatment records (STRs) are silent for any complaints or treatments for his knees. In February 1977, there is an entry indicating that the Veteran complained of low back pain after falling on ice the night before. There was no follow up treatment. In April 1977, the Veteran’s STRs contain a printed statement which the Veteran signed. It stated that the Veteran has been examined in the past 90 days and has been deemed physically qualified for separation. It also stated that the Veteran has not suffered any injuries or illness during his period of active duty. In April 1977, the Veteran’s discharge records indicate that he has a very clearly defined tendency to somatize and use his physical symptoms to manipulate his environment. In September 1978, the Veteran submitted a statement regarding his alleged in-service fall. He stated that in March 1977, he was told to get into formation outside of a hall where it was icy. He was walking into formation when another recruit slipped and fell behind him, knocking him down on his back. The Veteran stated that at the time he was in basic training and did not have leave, he was on duty twenty-four hours per day, seven-days per week. In November 1997, the Veteran’s VA treatment records indicate that he complained of bilateral knee pain and that his X-rays revealed minimal osteophyte formation at the margin of the joints, particularly on the left. There were no other definite abnormalities in the bones or the joints. The Veteran was diagnosed with mild degenerative joint disease. In October 1998, the Veteran’s VA treatment note indicated that he complained of pain in and around his right knee. He reported that the pain began the day before while he was going up the stairs with heavy packages. The Veteran had pain all night and decreased range of motion. He was able to ambulate with a limp. There was mild swelling and tenderness. In March 1999, the Veteran’s VA records indicate that the Veteran reported having left knee cartilage removal surgery in 1979 and 1980. In April 1999, the Veteran’s private treatment records indicate that he underwent an operation to repair a degenerative tear of the posterior horn of the medial meniscus of the left knee. He was noted to have minimal to moderate degenerative joint disease. There were no noted complications. In June 1999, the Veteran’s VA treatment records indicate that he presented for physical therapy after recovering from his April 1999 knee surgery without complications. The Veteran presented with pain, edema, decreased range of motion, decreased strength, and gait dysfunction. He was recommended to participate in at least 4 to 6 sessions. There was no mention of loss of immobility. In December 1999, the Veteran’s VA physical therapy note indicates that the Veteran complained of knee pain upon touch and it was noted that it was doubtful that the Veteran’s pain will improve. There is no record of the Veteran participating in physical therapy on a regular basis. In April 2001, the Veteran’s VA treatment note indicates that he has experienced chronic bilateral knee pain for two years. He reported having a left knee arthroscopy in 1999 and told he had arthritis and that the was nothing to be done except total knee replacement, for which he is too young. The Veteran indicated that he has pain all the time, even when he is sitting in a chair. He reported that his knees swell when is on the knee or when he is around the house on crutches. The Veteran was noted to have unorthodox ideas about treatment, including working with a homeopathic provider to correct the imbalance caused by his arthritis. With regard to diagnosis, he was noted to have chronic bilateral knee pain, osteochondritis desiccans, with reported left knee surgery in 1979, 1980, 1994, and left knee arthroscopy partial meniscectomy in May 1999 with knee pain on and off. In August 2001, the Veteran’s VA records indicate that he reported not being interested in physical therapy. In March 2002 the Veteran’s VA treatment note indicated that he continues to complain of knee pain, which he is treating with ibuprofen. The Veteran also requested that he is only treated with “natural” management of his problems and declined any injections. The VA treating physician noted that the only available records were X-rays from 1999 which indicated moderate osteoarthritis in the left knee and mild osteoarthritis in the right knee. In December 2003, the Veteran’s VA X-rays indicated that he has osteoarthritis of the left knee with minimal degenerative changes noted at the patellofemoral joint. In July 2006, the Veteran’s VA treatment notes indicate that he was examined by a VA doctor due to his mobility problems. The Veteran reported that he has been using a manual wheelchair since his May 1999 left knee surgery and that he is not able to stand up or walk at all. He also reported that his CTS prevents him from propelling the manual wheelchair. The VA physician indicated that the examination was very limited because the Veteran complained of pain with any kind of light touch. The Veteran’s knee range of motion appeared fine. There was no swelling or erythema of the knees. The VA physician concluded that it is unclear why the Veteran is not able to stand up and ambulate 7 years after his left knee surgery. There is no medical justification for this Veteran to meet the criteria for motorized mobility equipment. The VA physician also noted that the Veteran was examined for this same problem in December 2003 and the notes from the examination state that he has no medical need for motorized mobility. The Veteran was noted to be swimming. It was noted that it is unclear why the Veteran is wheelchair bound and unable to ambulate and that he needed to undergo an orthopedic clinic evaluation, MRIs, and other treatments to determine why he is bound to a wheelchair. The Veteran was recommended to schedule an evaluation with an orthopedic clinic to evaluate his knees for the exact problem and etiology that is preventing his mobility. He was also recommended an MRI and physical therapy. The Veteran refused all of the recommendations. The Veteran’s VA physician indicated that the Veteran will not be able to find out why he has mobility problems without the recommended evaluations. In April 2007, the Veteran submitted a statement indicating that his in-service fall occurred in February 1977 and that he fell forward on ice, on his knees and hands, then got up and was pulled backwards and fell back on his back. He alleged that his knee and hand injuries were not examined and he was not provided medical care. He was given light duty and pain medication. He needed to be hospitalized and instead was put in a psychiatric ward and then took an honorable discharge. The Veteran stated that he had two knee surgeries in 1979 and one in 1980. In August 2007, the Veteran’s VA X-rays indicate that he has degenerative changes in the left knee. In a follow up note that same month, the Veteran reported swimming every day and being happy with how he feels physically. He noted pain in left knee even when sitting and worse with activity. He continues to treat his pain with ibuprofen. In October 2007, the Veteran’s VA treatment notes indicate that he reported being wheelchair bound due to his knee pain and requested an electric wheelchair. In December 2007, the Veteran’s VA orthopedic prosthetics consultation note indicates that the Veteran and his wife refused to allow ramping to be installed to the front entrance of his home. The Veteran requested that instead the VA ramp the back entrance of his house and install and pave a forty-foot concrete walkway. The paving of the walkway would not be covered for funding and it was suggested that a side door be installed and ramped, as this would be covered. The Veteran requested to hold off on this suggestion pending his VA claims. In January 2009, the Veteran’s VA primary care physician drafted a note indicating that he received an employability assessment from the Pennsylvania Department of Welfare, which stated that the Veteran had 5 left knee surgeries with the last one being in April 1999 and uses a special amputee wheelchair and cannot walk. The Veteran’s VA doctor indicated that the Veteran is permanently disabled due to osteoarthritis of the knees as well as osteoarthritis of the spine and carpal tunnel syndrome. In June 2009, the Veteran submitted a letter from Dr. P.P. Dr. P.P. stated that the Veteran is not a client of his but has reached out to him after reading one his articles regarding irritable bowel syndrome. Dr. P.P. stated that the Veteran has injuries to his knees, back, and hands as a result of an accident that occurred in February 1977 and has been prescribed pain relivers since that year. Dr. P.P. also stated that the Veteran developed chronic constipation associated with use of pain relievers. The Veteran also developed arthritis which can develop from chronic constipation. Dr. P.P. cited and attached several medical articles indicating that constipation can cause arthritis and also set off an autoimmune response. However, these articles indicate that constipation can cause arthritis through a concept called “leaky gut syndrome”, and the attached literature indicates that “leaky gut syndrome” is not a term accepted within conventional medicine. In December 2009, the Veteran underwent a VA examination for his claim. The Veteran was in a wheelchair and declined a physical examination of his knees. The Veteran reported that five days after he enlisted, he fell on ice and was hospitalized for 30 days. He was treated for his bilateral knee condition during this hospitalization. The VA examiner was unable to find any documentation regarding the injury or the subsequent hospitalization. The Veteran reported that he continued to have knee pain after discharge and underwent left knee surgery in 1979, two years after discharge. He underwent arthroscopic surgery for his right knee in November 1998, approximately 19 years after service. The Veteran contended that since the 1998 surgery, his knees have gotten progressively worse and led him to being wheelchair bound. The Veteran declined range of motion testing, repetitive motion testing, and contended that the examination would result in a flare up of his knee pain. The Veteran was diagnosed with a moderate chronic bilateral knee strain. The VA examiner concluded that the Veteran’s bilateral knee disabilities are not associated with irritable bowel syndrome and chronic constipation. The VA examiner indicated that there is also no evidence that chronic bilateral knee strain leads to osteoarthritis. In December 2011, the Veteran’s physical rehabilitation note indicated that the Veteran requested an evaluation for a motorized wheelchair. He was noted to live in a one-story ranch home with three steps leading up to the entrance. The Veteran reported that he was already approved for a motorized wheelchair but there was no further follow up. The Veteran was ordered to have his house evaluated for ramping access by the motorized wheelchair. In May 2012, the Veteran’s VA physical rehabilitation note indicated that Veteran requested an evaluation for a motorized wheelchair again. The Veteran indicated that he is unable to ambulate and uses several manual wheelchairs to get around the house. It was noted that the Veteran was already evaluated for getting a wheelchair in 2007 but refused to have ramping installed for the wheelchair to access his house. Accordingly, no wheelchair was approved by the VA. The May 2012 note goes on to state that the Veteran was told that he would have to have his house evaluated for ramping access before he was measured for a wheelchair. It was noted that the Veteran was quite upset and verbally abusive to the VA staff. The Veteran was told to make an appointment to be measured for a wheelchair once the ramping to access his house in a wheelchair has been approved. In May 2013, the Veteran’s VA treatment note indicates that he was seen for diabetes mellitus follow up. It was noted that the Veteran refuses to take medication for his diabetes, wishing to only treat it with alternative herbal medications. In June 2013, the Veteran’s VA treatment records indicate that the Veteran comes every few months for his blood check and refuses medical care. He refuses to take medication against medical advice and reports only using alternative herbal medications. The Veteran was noted to be doing all care against medical advice. The Veteran was noted to use a medical provider who is not medically trained and uses herbal medications. In January 2014, the Veteran’s VA records indicate that he informed the VA that he cannot attend his scheduled VA examinations because he cannot get in the elevator due to vertigo, dizziness, being wheelchair bound, and not being able to sit for long periods of time. In November 2014, the Veteran’s VA doctor, Dr. L.R. submitted a letter, indicating that he suffers from severe and permanent disability due to the following conditions: degenerative joint disease “w/” osteoarthritis in bilateral knees, bilateral carpal tunnel syndrome with osteoarthritis in hands, bilateral bones spurs in thumbs, degenerative changes in lumbar and sacral spine, and is wheelchair bound due to conditions listed. Dr. L.R. indicated that the Veteran should qualify for permanent accommodations to assist with activities of daily living. In December 2015, the Veteran’s VA primary treatment records indicate that the Veteran was seen for an unscheduled nurse clinic assessment for low back pain. The note indicates that the Veteran drove himself to the assessment and was using his own wheelchair. The Veteran’s wheelchair did not have footrests, which the Veteran indicated he does not like. The Veteran uses a wheelchair because of his bad knees causing him to fall. In March 2016, the Veteran’s VA therapy evaluation notes indicated that the Veteran reported having legal issues that resulted in him requiring to participate in court-ordered therapy for unknown reasons, possibly “narcissism” based on the evaluation of the court psychiatrist. The Veteran reported that during this evaluation, he shared that he thought all his facts were wrong. In April 2016, the Veteran submitted a correspondence indicating that he requires all of the correspondence sent to him to be in at least 16 size font Courier New due to vision problems (a request he has made numerous times without submitting any medical records substantiating that he cannot read documents in different fonts or smaller sizes). The Veteran’s file contains a July 2016 prisoner data report from Bucks County Department of Corrections indicating that the Veteran was confined in February 2016. There is also another March 2017 prisoner data report similarly indicating that the Veteran was confined in August 2016. A December 2018 VA Form 27-0820e indicates that the Veteran was arrested in February 2016, convicted of a misdemeanor charge in August 2016, released from jail in October 2016 with no further action taken due to the offense being a misdemeanor charge. In December 2018, the Veteran’s VA records indicate that he called the nurse triage line and complained of left knee pain, leg swelling, localized pain below painful knee. He reported being nonambulatory and confined to a bed or a wheelchair. The Veteran was advised to go to the VA Emergency Room. The Veteran’s December 2018 Emergency Room notes indicate that he is able to stand and pivot and maneuver onto the stretcher independently. The Veteran reported that he may have a blood clot as he read about it online while trying to diagnose himself. Upon physical examination, there was no palpable cord or popliteal mass, no pedal edema, no Homans sign, and no venous cords bilaterally. After a vascular lab study, the Veteran was deemed stable and discharged. In January 2019, the Veteran’s VA primary care note indicates that he reported having knee cartilage removed while in service. The year provided was 1999. In February 2019, the Veteran reported that he is unwilling to attend an examination in support of his remanded appeal. He indicated that he attended a previous examination and had a very bad experience with the doctors. He was offered to have an examination with a contractor instead of a VA examiner or have the examination take place at a VA center of his choice, and he again refused. A June 2019 VA neurology consultation note indicated that the Veteran had a minor stroke. During the consultation, the Veteran reported being discharged from the military due to injury. June 2019 VA endocrinology consultation notes indicated that the Veteran is limited to a wheelchair because of knee pain and that his past surgery history includes left knee surgery in 1975 to remove cartilage, and April 1999 left knee arthroscopy. In October 2019, the Veteran’s VA neurology note indicated that the Veteran’s motor systems were examined. There was no muscle wasting or fasciculation, and his muscle strength was full. There was no tremor, no rigidity, or bradykinesia. His knee to heel coordination was normal. In addition to this evidence, the Veteran submitted statements from his family members indicating that after discharge, the Veteran began having knee and hand problems. Based on the above, the preponderance of the evidence is against the Veteran’s claim. The Veteran’s bilateral knee disability did not have its onset in service, did not manifest to a compensable degree within one year of discharge, and is not otherwise causally related to the Veteran’s service, to include his service-connected constipation. Accordingly, service connection for bilateral knee disability, to include secondary to service-connected constipation is denied. As previously mentioned, a review of the Veteran’s STRs did not contain any complaints or treatments for knee pain or injury. The notation regarding the alleged slip and fall only references back pain and does not reference follow up treatment. Further, the notation does not indicate that the Veteran suffered any significant injury that would require treatment or hospitalization. In this regard, the Veteran has not been a credible historian. In his September 1978 statement, the Veteran reported falling backwards. In his April 2007 statement, the Veteran reported falling forward on his knees and hands, getting up, and then falling for the second time (this time backwards), and injuring his back. The Veteran has also provided inconsistent statements regarding the medical treatment he claims to have received for this injury. In the September 1978 statement, the Veteran indicated that he did not get any time off or light duty following the injury. In his April 2007 statement, the Veteran stated that he was given light duty and pain medication following his slip and fall. During his December 2009 VA examination, the Veteran reported that he was hospitalized for 30 days following his in-service slip and fall injury, which, as noted above, is not shown in the STRs. Perhaps more glaring are the inconsistent statements with respect to having surgeries immediately following this alleged injury. During his December 2009 examination, the Veteran reported having left knee surgery in 1979, two years after discharge and again in 1989, nineteen years after discharge. In an April 2001 VA treatment note, the Veteran reported having knee surgeries in 1979, 1980, 1994, and May 1999. In a January 2009 statement, the Veteran indicated that he had five knee surgeries with the April 1999 surgery being his fifth. In the April 2007 statement, the Veteran reported having two surgeries in 1979 and one in 1980. In January 2019, in a VA treatment note, the Veteran reported having knee surgery in 1999, while in service. Then, in a June 2019 VA treatment note, the Veteran reported having surgery in 1975 and April 1999. Notably, the Veteran has not provided any corroborating medical documentation to support his assertions regarding any knee surgeries prior to 1999. While it is certainly possible that the January 2019 VA treatment note indicating that the Veteran knee surgery during service in 1999 was an error by the examiner in recording the Veteran’s self-reported history, there are nonetheless numerous other inconsistent statements regarding the Veteran’s self-reported history as noted above, and as described below. Given the numerous inconsistent statements as to his past knee surgeries, coupled with the absence of any corroborating documentation of any knee surgery prior to 1999, the Veteran’s statements regarding continuity of treatment during and after service lack credibility and are of diminished probative value. Indeed, the earliest that the Veteran’s records contain objective medical evidence of any sort of treatment for a knee disability is in the November 1997 VA X-rays, over twenty years after discharge. Accordingly, due to the lack of credibility afforded to the Veteran’s lay testimony, the Board finds that there is no probative evidence of any in-service injury or disease upon which to base direct service connection. Here, the Veteran’s service treatment records appear complete (including entrance exam, separation exam statement, dental records, in-service treatment records), and they do not show that the February 1977 fall on ice involved the Veteran’s knees or presented an injury requiring treatment. To the contrary, there is a discharge statement indicating that the Veteran has a very clearly defined tendency to somatize and use his physical symptoms to manipulate his environment. There is also a statement that the Veteran signed indicating that he did not have an injury during service. Accordingly, it is reasonable to infer that had the Veteran experienced a slip and fall injury that caused him to injure his knees, be hospitalized for up to thirty days, and cause numerous surgeries, it would have been reported and recorded as such in the Veteran’s STRs, particularly given the Veteran’s tendency to somatize. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011) (stating that the Board, as fact finder, is permitted to draw inferences based on the evidence, so long as any such inference does not result in a medical determination); United States v. Vasquez, 677 F.3d 685, 692 (5th Cir. 2012) (stating that fact finders "may properly use their common sense and evaluate the facts in light of their common knowledge of the natural tendencies and inclinations of human beings" (internal quotations omitted)). Because the STRs are absent of any extended hospitalization for any knee injury associated with the documented slip and fall on the ice, and given the Veteran’s lack of credibility, the Board finds that the Veteran did not injure his knees during service. Due to the lack of substantiated in-service knee injury, or disease, the Veteran’s claim for service connection fails on a direct basis. There is no probative medical evidence suggesting that the Veteran’s bilateral knee disability is the result of his military service which lasted for just over two months. The only evidence in support of this claim is the Veteran’s own self-reported history, and lay statements that were purportedly provided by family members. Certainly, the Veteran, as a lay person, is competent to report observable symptoms such as pain. See Barr v. Nicholson, 21 Vet. App. 303, 308-310 (2007). However, it is clear, based on a detailed review of the statements overall, that the Veteran and his family do not have specialized knowledge of medicine in general, and are merely speculating on whether there is a causal relationship between his disability and service. The Veteran submitted several statements attempting to describe alleged medical terms and processes (ex. “the leaky gut syndrome”), and attempted to pass them along as a widely-accepted medical concept. Fact remains, that the probative medical evidence of record and actual widely-accepted medical concepts all contradict the Veteran’s assertions. In this regard, the Veteran is not competent to formulate a nexus opinion in this case, as such knee diagnoses and the cause of them requires specialized medical knowledge and specific testing. See 38 C.F.R. § 3.159 (stating that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). As such, the Veteran's lay statements regarding his medical history and nexus to service, are lacking in probative value, and are far outweighed by other evidence of record showing no in-service treatment for an injury or any other relationship between his bilateral knee disability and military service. In addition to the inconsistencies discussed above, the Veteran’s credibility is questioned with respect to his reports of the severity of his disability as well as his sincerity in treating his alleged disabilities. All of the X-rays that were taken throughout the period of appeal indicate that the Veteran’s bilateral knee osteoarthritis is minimal to moderate, and not severe or debilitating. However, the Veteran continued reporting that his disability is so severe, as to require use of wheelchair since the April 1999 surgery. However, as noted above, the Veteran’s VA treatment records indicate that there are no medical reasons for him to be in a wheelchair and that he has refused any further testing that would allow for VA doctors to figure out why he is immobile. His post-April 1999 surgery physical therapy notes do not mention need for a wheelchair or immobility. His April 1999 surgery did not have complications, despite the Veteran reporting that the VA “screwed up” his knee. A July 2006 VA treatment note indicates that there is no medical justification for the Veteran to meet the criteria for motorized mobility equipment, that this was the same conclusion in December 2003, and that it is unclear why the Veteran cannot ambulate. The Veteran was recommended to undergo an MRI of the knee, physical therapy, orthopedic consultation, in order to determine the etiology of his immobility. The Veteran declined treatment recommendations and continued representing himself as immobile due to knee pain despite being notified by multiple physicians to the contrary. More recently, the Veteran’s December 2018 VA emergency room records indicate that he is able to stand up, pivot, and maneuver onto the stretcher on his own, despite claiming for years that he is unable to stand up. Moreover, the Veteran was noted to drive himself to his medical appointment in December 2015 and the Veteran’s limited physical examinations have revealed that he has normal muscle strength, no atrophy and normal knee to ankle coordination. The record also contains a consistent pattern of the Veteran refusing medical treatment and medical examinations. After his April 1999 knee surgery, he refused to participate in any physical therapy despite complaining of pain and reporting that he lost his mobility. In July 2006, the Veteran refused a physical examination because of alleged pain and refused to follow any proposed course of testing and treatments. In May 2013, the Veteran refused to take prescribed medication to treat his diabetes, indicating he only wishes to take herbal treatments. In June 2013, the Veteran declined to take any medical advice and treatments and insisted using his own medical provider. To date, the Veteran has refused to treat his bilateral knee disability or his CTS with injections. The Veteran has made serious allegations regarding the severity of his disabilities, indicating that the medical record in this case clearly supports these contentions. However, the medical record in this matter contains a plethora of instances of the Veteran alleging severe symptoms, refusing treatments to alleviate those symptoms, and then refusing further testing and examinations. Additionally, the Veteran has alleged that he has been immobile, even wheelchair bound, requesting that he be provided with a motorized wheelchair. However, the Veteran refused to install any sort of access ramping to enter his own home in a motorized wheelchair. He was offered installation of a side door with ramping and still refused. In order to enter the Veteran’s house, he has to walk up three steps of stairs. The Veteran has not indicated how he has been able to enter and exit his residence since 1999, which is when he claims to have become immobile. Additionally, as noted above, the Veteran has insisted that all correspondence from VA must be provided in at least 16 size font Courier New due to vision problems (a request he has made numerous times without submitting any medical records substantiating that he cannot read documents in different fonts or smaller sizes). Yet, there is nothing in the record showing that the Veteran’s “vision problems” have affected his ability to drive. Pursuant to the last Board remand, the Veteran was scheduled for an additional VA examination in order to secure a nexus opinion and address the Veteran’s contentions. However, the Veteran cancelled the examination indicating that he will not attend any future examinations as he is unable to ride the elevator due to vertigo, is wheelchair bound, and is unable to sit for prolonged periods of time. Yet, the record affirmatively shows that the Veteran is quite capable of driving himself to and from a VA medical center to receive medical treatment. Given the record in this matter, the Board finds that the Veteran did not show good cause to fail to report to his examinations. When a Veteran fails to report for a required examination in connection with an original claim, a decision must be made on the evidence of record. 38 C.F.R. § 3.655. Accordingly, any further development of the Veteran’s claim has been precluded by his failure to participate in the scheduled VA examinations. Moreover, the Veteran has refused MRIs and other knee testing deemed necessary by medical providers to determine the current nature and likely etiology of any current knee disability. Significantly, the duty to assist is not always a one-way street. “If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). VA has the discretion to determine when additional information is needed to adjudicate a claim. The Veteran is expected to cooperate in the efforts to adjudicate his claim for service connection. His failure to do so subjects him to the risk of an adverse adjudication based on an incomplete and underdeveloped record. Kowalski v. Nicholson, 19 Vet. App. 171 180-181 (2005). With respect to the Veteran’s claim that his bilateral knee arthritis is caused by his service-connected constipation, there is no competent or probative evidence that links the two disabilities. While there is a June 2009 private medical opinion by Dr. P.P., the opinion is not assigned probative value. The opinion it is not supported by a rationale that explains the basis for the conclusion reached. See Stefl v. Nicholson, 21 Vet. App. 102, 124-25 (a medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (a medical report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). Indeed, the opinion does not indicate that the Veteran’s records were reviewed and does not provide any rationale with respect to the Veteran’s specific etiologies. To the contrary, Dr. P.P. clearly stated that the Veteran is not his client. Dr. P.P. indicated that arthritis can be developed by constipation through “leaky gut syndrome” and attached medical literature regarding these issues. However, the medical literature clearly states that “leaky guy syndrome” is not generally recognized by conventional physicians. Dr. P.P.’s June 2009 opinion and supporting literature are of diminished probative value because they do not pertain to the Veteran’s etiology and discuss medical concepts that are not generally recognized within the field of conventional medicine. Moreover, the December 2009 VA examination report indicated that there is no medical literature that supports a finding that there is a connection between constipation and arthritis. In sum, given the Veteran’s diminished credibility as a historian, lack of notations in the Veteran’s STRs, and lack of chronicity of treatment or symptoms, the preponderance of the evidence is against a finding that the Veteran suffered an in-service injury or disease upon which service connection can be based. Additionally, the weight of the probative medical evidence is against a finding that the Veteran’s bilateral knee disability is otherwise causally related to his service, to include his service-connected constipation. Accordingly, the Veteran’s claim is denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt rule enunciated in 38 U.S.C. § 5107(b). However, as there is not an approximate balance of evidence, that rule is not helpful to the Veteran. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). 2. Entitlement to service connection for right-hand CTS. The Veteran seeks service connection for right-hand CTS. He contends that he developed CTS as a result of his in-service February 1977 fall on ice. In his October 2007 statement, the Veteran indicated that the VA gave him a wheelchair due to pain in his legs and numbness in hands. He could not propel a regular wheelchair with his hands due to CTS. He also indicated that in January 2004 he was given a custom wheelchair to accommodate the fact that he could not grasp a wheelchair due to his CTS splints. He stated his CTS became worse in January 2007 by the treatment he had received from the VA. The record with respect to the Veteran’s medical history and other contentions is discussed above. In addition, the Veteran’s VA treatment records indicate that the Veteran was recommended to have the CTS surgically repaired, but he declined to undergo the surgery in at least August 1996, December 1996, March 1998, and September 2001. In August 1996, the Veteran’s VA treatment records indicated that he has bilateral CTS and wears splints. In September 1996, the notes indicated that the Veteran reported having no problems with CTS, not wearing the splints at night, and having stable symptoms. In June 2001, the Veteran’s VA treatment notes indicated that he complained of numbness or tingling in both hands, all digits, which he has had since 1980. He reported that his CTS has been worsening and that his splints give him no relief. Upon physical examination, the Veteran was noted not to have any atrophy, having full range of motion on all joints, and having subjective decrease in sensation in all digits. In September 2001, the Veteran’s VA treatment notes indicated he was counselled to use the splints and to take motrin for his CTS. In March 2002, the Veteran’s VA treatment records indicated that he refused to treat his CTS with any injections. In October 2007, the Veteran’s VA treatment note indicates that he requested a motorized wheelchair and reported that his CTS gets aggravated from propelling a regular wheelchair. He was evaluated as a result. He indicated that his wrists hurt and there is some numbness in the left lateral three digits. He reported there not being significant progression of his symptoms. A March 2007 X-ray report indicated that there were no prior studies available for comparison and that there is no acute traumatic abnormality nor focal destructive lesions seen. There is mild osteo degenerative disease scattered in the interphalangeal joints of the fingers and at the first carpometacarpal joint in the left hand. There are small calcified loose bodies adjacent to the joint which may be from old trauma. The soft tissues appear intact. A September 2007 EMG was cited as illustrating right median motor and sensory showing prolonged latencies and normal amplitudes. It was noted that a needle EMG study was not needed given the nerve conduction study results. The findings of the September 2007 EMG indicated right moderately severe CTS. It was recommended that the Veteran speak to a hand surgeon. It was noted that the Veteran refused a study for his left wrist. The Veteran’s wrist was examined, it was noted that he had a tender right wrist, no swelling, slightly limited range of motion, and no wasting. The evaluation ended with the Veteran needing to follow up for an evaluation of his home for a wheelchair. In March 2009, the Veterans VA treatment records indicate that he requested that his VA doctor provide him a note exempting him from using a seatbelt while driving or being driven in a car because it is difficult for him to put his seatbelt on due to CTS. He also stated that it hurts to wear a seatbelt due his disabilities. The Veteran reported that he was pulled over and issued a citation for being a passenger in a motor vehicle without wearing a seatbelt. In May 2012, as discussed above, the Veteran’s records indicate that he made one of many requests to be evaluated for a motorized wheelchair. The note indicates that the Veteran reported having a history of severe CTS and was not a candidate for surgery. The VA noted that he has refused surgery in the past. In December 2013, the Veteran’s VA treatment records indicate that the Veteran had normal bone density and only minimal sclerosis at the right first metacarpal-phalangeal joint. There is a small osseous fragment at the base of the left first metacarpal bone, presumably an old ununited avulsion. There is mild degenerative joint disease at the interphalangeal joints of both thumbs. There is mild bone spurring and subchondral cyst at the interphalangeal joints, both proximally and distally of most of the fingers of both hands. In April 2014, the Veteran’s VA emergency room note indicates that the Veteran presented with complaints of burning pain from the palmar crease radiating to the fingertips in the fourth and fifth digits of his left hand. The Veteran denied injury but felt that his hand was broken. He stated that his daughter saw a bruise on his hand that he cannot see. It was noted that the Veteran does not want to take any conventional medicine for any ailments. Prior to getting the lab results back, the Veteran stated that he wanted to leave. The Veteran was told that if his injury is serious he would have to be admitted. The Veteran adamantly refused treatment and promised that he would follow up with his primary doctor. Based on the above, the preponderance of the evidence is against the Veteran’s claim. The Veteran’s right-hand CTS did not have its onset in service, did not manifest to a compensable degree within one year of discharge, and is not otherwise causally related to service. Accordingly, the claim is denied. As discussed with the Veteran’s bilateral knee disability claim, the Veteran’s February 1977 in-service fall did not involve injury to the Veteran’s wrist that required treatment or hospitalization. There is no mention of the Veteran falling on his hands or wrists, having pain in his hands or wrists, or being treated for any symptoms associated with his hands or wrists. The remainder of the Veteran’s STRs are also silent for any complaints or treatments for a wrist or hand injury, or any other in-service injury as confirmed by his discharge statement. The records indicate that the first instance of the Veteran having been diagnosed with CTS is in September 2001 through an EMG. This diagnosis was rendered over twenty years after service. While the Veteran contends that he was diagnosed with CTS in 1979 or 1980, there are no records that support these contentions. Given the inconsistencies with respect to the Veteran’s statements, his lay statements with respect to onset of his disability are of diminished probative value. Accordingly, the record supports a finding that the Veteran’s CTS did not have its onset in service or within one year of discharge. Furthermore, there is no substantiation that an in-service injury on which service connection may be based ever occurred, and the Veteran’s claim fails on a direct basis. The only evidence that supports the claim is the Veteran’s own self-reported history. As previously mentioned, he is not competent to formulate a nexus opinion as to the etiology of CTS, as such diagnoses and the etiology of them requires specialized medical knowledge and specific testing. See 38 C.F.R. § 3.159 (stating that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). As such, the Veteran’s lay statements regarding his medical history and nexus to service, are lacking in probative value, and are far outweighed by other evidence of record showing no in-service treatment for an injury or any other relationship between his right-wrist CTS and military service. As with his bilateral knee disability, the Veteran has also refused to participate in any VA examinations without good cause shown. When a Veteran fails to report for a required examination in connection with an original claim, a decision must be made on the evidence of record. 38 C.F.R. § 3.655. Therefore, any further development of the Veteran’s claim has been precluded by his failure to participate in the scheduled VA examinations. It is additionally emphasized that the duty to assist is not always a one-way street. “If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). VA has the discretion to determine when additional information is needed to adjudicate a claim. The Veteran is expected to cooperate in the efforts to adjudicate his claim for service connection. His failure to do so subjects him to the risk of an adverse adjudication based on an incomplete and underdeveloped record. Kowalski v. Nicholson, 19 Vet. App. 171, 180-181 (2005). In summary, the most probative medical evidence of record is against a finding that the Veteran’s right-wrist CTS had its onset in service, manifested to a compensable degree within one year of service, and is not otherwise causally related to the Veteran’s active service. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt rule enunciated in 38 U.S.C. § 5107(b). However, as there is not an approximate balance of evidence, that rule is not helpful to the Veteran. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Kuksova The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.