Citation Nr: 21003293 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 12-22 535 DATE: January 21, 2021 ORDER Entitlement to a rating in excess of 10 percent for status post left medial meniscectomy with residual degenerative joint disease is denied. Entitlement to a compensable rating for hypertension is denied. Entitlement to service connection for a right knee disability, to include as secondary to a service-connected left knee disability, is denied. FINDINGS OF FACT 1. The Veteran’s status post left medial meniscectomy with residual degenerative joint disease is assigned the maximum rating for cartilage, semilunar, removal of, symptomatic; this rating contemplates painful motion. 2. The Veteran’s left knee disability does not manifest in cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint; extension to 10 degrees or greater; flexion to 45 degrees or less; or subluxation or lateral instability. 3. The Veteran’s hypertension is not manifested by a diastolic pressure of predominantly 100 or more or systolic pressure predominantly 160 or more; nor is there probative evidence he has a history of diastolic pressure predominantly 100 or more requiring continuous medication. 4. The Veteran did not exhibit a right knee disability in service, arthritis of the right knee did not manifest to a compensable degree within one year after discharge from service, and such disability is not otherwise shown to be associated with active service or with a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent for status post left medial meniscectomy with residual degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-5263. 2. The criteria for a compensable rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.104, Diagnostic Code 7101. 3. The criteria for entitlement to service connection for a right knee disability, to include as secondary to a service-connected left knee disability, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1977 to July 1982 in the U.S. Marine Corps and from November 1983 to May 1989 in the U.S. Coast Guard. This matter comes before the Board on appeal from an October 2010 Regional Office (RO) rating decision. In March 2015, the Veteran testified at a hearing before an Acting Veterans Law Judge. The Veteran was informed via a March 2018 letter that the Acting Veterans Law Judge who had conducted the March 2015 videoconference hearing was no longer with the Board. The letter informed him that he could request a hearing with a new Veterans Law Judge who would then be able to decide his appeal. The Veteran did not reply to this letter, and the Board has proceeded with the adjudication of this appeal. Increased Rating Disability ratings are determined by comparing a veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. “Staged ratings,” or different percentage evaluations for separate periods based on the facts found, may also be awarded. Fenderson v. West, 12 Vet. App. 119, 126-7 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). 1. Entitlement to a rating in excess of 10 percent for status post left medial meniscectomy with residual degenerative joint disease is denied. Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45. See generally DeLuca v. Brown, 8 Vet. App. 202 (1995). Pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance, in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Actually painful, unstable, or malaligned joints due to healed injury are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Joints are to be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and, if applicable, with the range of the opposite, undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Estimates of additional functional impairment during flare-ups, if any, are also to be recorded, or an explanation with adequate rationale must be given as to why such estimates are not possible. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Knee disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5263. Included within 38 C.F.R. § 4.71a are multiple diagnostic codes that evaluate impairment resulting from service-connected knee disorders, including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum). The Veteran’s left knee disability is currently assigned a 10 percent rating (for symptomatic removal of semilunar cartilage) under Diagnostic Code 5259. This is the highest rating that is available under that diagnostic code. The Board has therefore considered whether additional or higher ratings may be assigned under another diagnostic code or codes. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). The Veteran testified at his 2015 Board hearing that he has trouble going up and down stairs and that both knees bother him. He reported that he has to crawl up and down the stairs or go up and down while sitting. He reported that his kneecap pops out if he twists or turns and almost feels as if it is being dislocated. The Veteran’s representative suggested that there may be some instability, and the Veteran reported that he fell on the stairs when his knee went out and he lost his balance. Turning to the applicable rating criteria, in the absence of ankylosis, the Board finds that entitlement to a compensable rating under Diagnostic Code 5256 is not warranted. The Board has considered whether the Veteran’s meniscal pathology would more appropriately be rated under Diagnostic Code 5258. This diagnostic code provides a 20 percent rating for cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint. The May 2010 and June 2010 VA examination reports note that, while there was pain, there were no episodes of locking or effusion. The January 2018 VA examination report notes that the Veteran had a left meniscal tear, but it does not note frequent episodes of locking, joint pain, or joint effusion. The October 2018 VA examination report notes that the Veteran had a left meniscal tear and has frequent episodes of joint pain, but he does not have frequent episodes of locking or joint effusion. The Veteran’s VA medical records do not contain contradictory findings. Thus, the Board finds that the Veteran’s left knee disability does not satisfy the criteria for a 20 percent rating under Diagnostic Code 5258. In the absence of allegations or findings of tibia/fibula impairment and genu recurvatum, the Board finds that the criteria for compensable ratings under Diagnostic Codes 5262 and 5263 are not met. Separate ratings may be assigned for instability (under Diagnostic Code 5257) and under Diagnostic Codes 5258 or 5259 for meniscal pathology (under Diagnostic Code 5258 or 5259). VA Gen. Counsel. Prec 23-97 (July 1, 1997); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The Board has therefore considered whether a compensable rating may be assigned under Diagnostic Code 5257 in addition to the 10 percent rating that is in effect under Diagnostic Code 5259. Under Diagnostic Code 5257, slight recurrent subluxation or lateral instability warrants a 10 percent rating, moderate recurrent subluxation or lateral instability warrants a 20 percent rating, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. The Board notes that the May 2010 and June 2010 VA examination reports note that the Veteran denied instability or subluxation and that no instability was found on examination. The October 2018 VA examination report notes that the Veteran reported that his left knee feels unstable. However, the January 2018 and October 2018 VA examination reports expressly note findings of no recurrent subluxation or lateral instability on examination. They additionally note that there was no anterior instability, posterior instability, or medial instability. As noted above, the Veteran reported having had his left knee give out while on the stairs and that he has to go up and down stairs either on his knees or while sitting. A November 2012 private medical record notes that the Veteran’s knee gave out when he was walking down stairs. However, no ligamentous laxity was present on examination at that time. The Board notes that the only indication of possible instability appears in the Veteran's own reports of his knee giving out. All joint stability tests, however, have been normal and there is no medical evidence of patellar subluxation or lateral instability of the knee. Indeed, just because the Veteran perceives that a symptom experienced is of orthopedic origin does not necessarily make it so, or that the term he used to describe the functional impairment accurately depicts the functional impairment. As the medical evidence and examinations show that the Veteran does not exhibit actual instability or subluxation, the Board will not make an independent medical judgment and conclude otherwise. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Also, because of the absence of findings of instability on examination, the Veteran's knee disability does not manifest in at least slight recurrent subluxation or lateral instability. Indeed, while the Veteran may be competent to report on symptoms and his perception of the degree of such symptoms, ultimately the opinion of the examiners in regard to the type and severity of functional impairment associated with a disability holds more probative weight because of the examiner's expertise in evaluating knee disorders. Cf. English v. Wilkie, 30 Vet. App. 171 (2018). Therefore, the Board finds that a separate rating under Diagnostic Code 5257 based on instability is not warranted. Separate ratings may be assigned for limited knee motion in flexion (under Diagnostic Code 5260) and in extension (under Diagnostic Code 5261), as well as for instability (under Diagnostic Code 5257). VA Gen. Counsel. Prec 23-97 (July 1, 1997). A separate compensable rating may also be assigned for meniscal pathology under Diagnostic Code 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017). The Board has therefore considered whether a separate rating may be assigned under Diagnostic Code 5260 and/or 5261. Under Diagnostic Code 5260, a 0 percent (noncompensable) rating is assigned for leg flexion limited to 60 degrees. A 10 percent rating is assigned for leg flexion limited to 45 degrees. A 20 percent rating is assigned for leg flexion limited to 30 degrees. A maximum 30 percent rating is assigned for leg flexion limited to 15 degrees. Diagnostic Code 5261 provides a 0 percent rating for leg extension limited to 5 degrees. A 10 percent rating is warranted where extension is limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating is warranted where extension is limited to 20 degrees. A 40 percent rating is warranted where extension is limited to 30 degrees. A 50 percent rating is warranted where extension is limited to 45 degrees. The March 2010 VA examination report notes that the Veteran reported pain that is worse with ambulation, prolonged sitting, and standing. He is able to walk a fourth of a mile and stand for 30 minutes. The June 2010 VA examination report notes that the Veteran reported chronic knee pain. Both examination reports otherwise contain the same symptom reports and findings. These records note that the Veteran takes over-the-counter medications with fair response. He reported giving way, pain, stiffness, weakness, and decreased speed of motion. He denied flare-ups or incapacitating episodes. On examination, flexion was to 130 degrees and extension was to 0 degrees. There was objective evidence of pain following repetitive motion, but there were no additional limitations. There was tenderness and pain at rest, crepitation, and grinding. There was no clicking or snapping, instability, patellar abnormality, meniscus abnormality, abnormal tendons or bursae, or other knee abnormality. The January 2018 VA examination report notes a diagnosis of status post left medial meniscectomy with residual degenerative joint disease. He reported having pain, giving out, loss of balance, and popping. He was not receiving current treatment. The Veteran denied flare-ups. He reported pain when walking and standing. On examination, flexion was to 120 degrees and flexion was to 0 degrees. Pain was noted on examination, but it did not result in or cause functional loss. There was no additional loss of function or range of motion after three repetitions. There was objective evidence of pain on passive range of motion testing. There was no objective evidence of pain when the joint is used in non-weight bearing. There were no additional contributing factors of disability. The October 2018 VA examination report notes that the Veteran’s flexion was to 90 degrees and extension was to 0 degrees. There was no evidence with pain on weight-bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was objective evidence of crepitus. There was no functional loss or loss of range of motion after three repetitions due to pain, but range of motion was still 90 degrees flexion and 0 degrees extension. There was no evidence of pain on passive range of motion testing or when the joint was used in non-weight bearing. Review of the VA and private medical records reflects that the Veteran has been treated for knee pain, but they do not contain range of motion finding that are more severe than those that are noted in the VA examination reports. The Board finds that entitlement to a separate rating based on limitation of flexion or extension is not warranted. The Board notes that none of the evidence of record reflects less than full extension. Thus, the criteria for a separate compensable rating under Diagnostic Code 5261 are not met. The Board notes that VA examination reports reflect limitation of flexion, but not of a degree to which a compensable rating is warranted based on range of motion alone. That is, there is no evidence of limitation of flexion to 45 degrees or less. As noted above, actually painful, unstable, or malaligned joints due to healed injury are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board notes, however, that Diagnostic Code 5259 compensates for symptomatic removal of semilunar cartilage. All of the above VA medical records expressly identify “pain” as a symptom of the Veteran’s left knee pathology. The Board concludes that, were it to award a separate rating for painful motion under Diagnostic Code 5260 or 5261, it would be compensating the Veteran twice for his left knee pain. This violates the prohibition against pyramiding and is not allowed. 38 C.F.R. § 4.14. In short, the Board finds that entitlement to a rating in excess of 10 percent for a left knee disability, either alone or combined with another compensable knee diagnostic code rating, is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 2. Entitlement to a compensable rating for hypertension is denied. The Veteran is in receipt of a 0 percent rating for hypertension under 38 C.F.R. § 4.104, Diagnostic Code 7101. Hypertensive vascular disease warrants a 10 percent rating when diastolic pressure is predominantly 100 or more, systolic pressure is predominantly 160 or more, or when an individual has a history of diastolic pressure predominantly 100 or more and requires continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code 7101. A 20 percent rating requires diastolic pressure of predominantly 110 or more or systolic pressure predominantly 200 or more. A 40 percent rating requires diastolic pressure of predominantly 120 or more. A 60 percent rating requires diastolic pressure of predominantly 130 or more. The March 2010 VA examination report notes that the Veteran was being treated with Metoprolol, which is a beta blocker. Blood pressure readings were 130/80, 132/80, and 134/82 mmHg on examination. The Veteran testified at his March 2015 Board hearing that he has run out of medication at times and that he monitors his blood pressure on his own. (See Board hearing transcript, pages 18, 20.) The January 2018 VA examination report notes that the Veteran takes Metoprolol 50 mg daily. Blood pressure readings were 133/80, 152/83, and 156/80 mmHg on examinations. Blood pressure readings appear throughout the Veteran’s VA medical records. The readings in these records are well within the range that is contemplated by the noncompensable rating. A July 2009 VA medical record notes that the Veteran’s “Blood pressure is elevated at this time. [He is] currently taking 50mg metoprolol daily. Home reading, of his bp ave about 125/85.” A February 2011 VA medical record notes that the Veteran “states he feels his bp is high, home readings are averaging about 150/90.” It was recommended that he follow a “low salt diet, increased mod exercise, to help with bp as well.” A March 2011 VA medical record notes that the Veteran “has been using [Metoprolol] 50mg daily and blood pressure has been variable, yesterday bp was mildly elevated.” (It was at 133/89.) His medication dosage was increased to 75 mg daily, and his “BP seems to be much better controlled.” A September 2012 VA medical record notes the following: “hypertension- controlled of medication now per pt.” It notes that the Veteran “states he has stopped bp medication, some time ago and his BP readings ave about 117/78.” A November 2012 VA medical record notes an initial blood pressure reading of 147/86 with a reading of 122/80 on repeat testing. A July 2014 VA medical record notes a blood pressure reading of 155/84. A November 2014 VA medical record notes a blood pressure reading of 137/73. An April 2017 VA medical record notes a blood pressure reading of 142/71. A May 2017 VA medical record notes a blood pressure reading of 104/69. An August 2017 new patient record for the Orlando VAMC notes that the Veteran’s high blood pressure is “controlled with present regimen.” A December 2017 VA medical record notes blood pressure readings of 114/72, 117/67, 138/72, 139/74, and 146/78. Another record from that date notes a blood pressure reading of 153/75. This record also notes that the Veteran was taking blood pressure medication at that time. A November 2018 VA medical record notes a blood pressure reading of 132/80. As reflected above, the Veteran’s blood pressure has not been predominantly 100 or more at any point during the appeals period. Nor has his systolic pressure been predominantly 160 or more at any point during the appeals period. The record reflects that at times during the appeals period, the Veteran has taken continuous medication to control his hypertension. The record does not reflect, however, that the Veteran has, or has any point had, diastolic pressure of predominantly 100 or more. For example, service treatment records note readings of 120/90 and 126/86, while a June 2001 VA medical record notes blood pressure of 131/86. The use of the conjunctive “and” in a statutory provision means that all of the conditions listed in the provision must be met. See Melson v. Derwinski, 1 Vet. App. 334 (1991). Because this condition is not satisfied, entitlement to a compensable rating is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. Service Connection 3. Entitlement to service connection for a right knee disability, to include as secondary to a service-connected left knee disability, is denied. Service connection is warranted where the evidence of record establishes that an 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; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, 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 may also be granted for listed chronic diseases, such as arthritis, if such were shown as chronic in service; manifested to a compensable degree within a presumptive period (usually one year) after separation from service; or were noted in service with continuity of symptomatology since service. 38 U.S.C. §§ 1112, 1113; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). A disability that is proximately due to, or results from, a service-connected disease or injury shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection on the basis of aggravation is permitted. 38 C.F.R. § 3.310(b). Compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability and not due to the natural progress of the nonservice-connected disease. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran contends that “The left knee I had surgery on in 1988, and I feel because of that surgery that I favored my left knee and put more pressure on my right knee, and therefore it, uh, started acting up just like the left knee.” (See Board hearing transcript, page 3.) He concurred with his representative’s statement that “you had right knee pain that developed shortly after surgery on the left knee,” as he had told the VA examiner during the January 2003 examination, and stated that his right knee problems started in 1988. (See Board hearing transcript, pages 24-25.) He reported that his left and right knee symptoms are “[p]retty much identical.” (See Board hearing transcript, page 25.) His daughter testified that she has “observed [the Veteran’s problems with his right knee] pretty much all my life. I mean, since I was little to be honest with you.” (See Board hearing transcript, page 26.) The Veteran reported that he has not seen a doctor for his right knee and that he basically just self-treated. (See Board hearing transcript, page 28.) He also stated that “both [knees] I would say are due to training in the military training, You’ve got to run, you’re carrying backpacks.” (See Board hearing transcript, page 3.) He also testified that he did not suffer a direct injury to the right knee in service. (See Board hearing transcript, page 24.) Service treatment records reflect that the Veteran’s right knee was found to be clinically normal when examined in July 1977, June 1982, April 1985, September 1987, and January 1989. He denied a history of, or current, trick or locked knee in his July 1977, April 1985, and September 1987 medical history reports. He reported a history of, or current, trick or locked knee in his January 1989 medical history report. However, he clarified in this record that these complaints pertained to his left knee. A June 1988 follow-up treatment record notes an assessment of patellar femoral syndrome. It does not note whether this record pertains to the left knee, the right knee, or both knees. However, a subsequent June 1988 record expressly notes that the Veteran has had a recurrence of left knee pain and lists an impression of torn medial meniscus. This record, along with multiple prior complaints of left knee, but not right knee, symptoms, strongly suggests that the earlier of the June 1988 records pertains to the left knee, but not the right knee. (See service treatment records dated in March 1988 and April 1988.) The Veteran subsequently underwent left knee arthroscopy and arthroscopic medial meniscectomy in July 1988. The Board notes that an August 1988 record notes right knee complaints and lists an assessment of “s/p R medial meniscectomy.” However, the Board notes that the Veteran had not undergone a right knee surgery, and that subsequent records reflect that the Veteran is status post left knee medial meniscectomy. (See August 1988 and September 1988 service treatment records.) Based on the above, the Board concludes that the Veteran’s service treatment records do not contain any complaints or treatment associated with his right knee. In terms of post-service history, a December 2000 VA medical record notes that the Veteran had “been having chronic knee pain (both knees).” The Veteran “states he has been having knee problems for many years, since in the marine/corp, and coast guard 7/88. pt states he first had left knee pain after jogging. pain cont. and pt had a surgical arthroscopy to take out some of the medial meniscus.” A February 2001 MRI report notes an impression was “[u]nder surface inner edge posterior horn medial meniscus” and “[j]oint accumulation.” A March 2001 VA medical record notes an assessment of “new tear rt [medial] meniscus.” The Veteran underwent a VA joints examination in January 2003. The resulting examination report notes that the Veteran has no history of trauma to his right knee. Following examination, he was diagnosed with a medial meniscus tear of the right knee. No etiology opinion was given. A June 2010 VA examination report notes that the Veteran has a right knee condition with an onset in the 1990s. It notes that the “Veteran states he has developed chronic right knee pain because [of] his service connected left knee condition. He states the pain in his right knee has prog[ressively] gotten worse.” Following review of the record and interview, examination, and diagnostic testing of the Veteran, the VA examiner diagnosed right knee degenerative joint disease. The examiner opined that this disability is less likely as not caused by or a result of service and less likely as not caused by the service connected left knee disability. As a rationale, the examiner noted that the Veteran’s “left knee is functional, no evidence of fusion, no leg length discrepancy.” The examiner also noted that there is “[n]o evidence in literature that right knee osteoarthritis is caused by a functional arthritic left knee.” Finally, he noted that “Also, there is no indication of a chronic or significant right knee injury in service.” The Veteran underwent a VA knee and lower leg conditions examination in January 2018. Based on review of the record and interview, examination, and diagnostic testing of the Veteran, the examiner diagnosed degenerative or traumatic arthritis. The examiner opined that this disability is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As a rationale, the examiner noted that “There is no documentation of record to support the [Veteran’s] claim of right knee injury during service. There is no chronicity of care.” The examiner also opined that the right knee disability is less likely than not due to or the result of the Veteran’s service-connected left knee disability. As a rationale, the examiner noted that “Arthritis in one joint does not cause arthritis in another joint. Medical literature does not support this. A nexus has not been established.” The examiner further noted that “There has been a 30 year gap from the time of left knee injury and no documentation to support chronic care of the right knee. Arthritis is a normal finding related to age progression.” The Veteran underwent a VA examination in October 2018. Based on review of the record and interview and examination of the Veteran, the examiner diagnosed right knee meniscal tear with a diagnosis date of February 2001 and right knee joint osteoarthritis with a diagnosis date of 2010. The examiner opined that the right knee osteoarthritis was less likely than not aggravated by the left knee disability. The examiner stated that the Veteran’s right knee osteoarthritis is age-related. The examiner was also directed to “address the Veteran’s contention that his service-connected left knee disability causes him to put excess strain on his right knee, resulting in injury/strain to his right knee. The examiner opined that the shifting weight would only occur in the standing position. He stated that his “calculations support a[n] increase of 15% to the contraalateral [sic] knee[.] This would not increase the knee getting OA/DJD.” He also noted that “In addition the knees are the same age and DJD/OA is commonly found in both joints[.] Shifting weight would not cause a strain or tear; which would be cause[d] by tangential force and not a vertical force.” The Board finds these opinions to be highly probative, as they were authored by individuals who possess the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). They are based on review of the record and interview, examination, and diagnostic testing of the Veteran. They contain rationale that cite to the facts of the Veteran’s case and pertinent medical principles. The only remaining contrary opinion comes from the Veteran himself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. The Board has also considered whether entitlement to service connection for osteoarthritis/degenerative joint disease of the right knee may be granted on a presumptive basis. As noted above, the Veteran has reported that his right knee symptoms began following his July 1988 left knee surgery. The Veteran was on active duty service at the time of this surgery and separated almost one year later, in May 1989. The Board notes, however, that the Veteran’s service treatment records do not reflect the presence of arthritis of the right knee during service. In addition, as noted above, the Board has determined that the Veteran’s service treatment records reflect that he did not complain of or seek treatment for any right knee symptoms during service. Given the Veteran’s treatment in service for left knee complaints, the Board finds it significant that there are none associated with the right knee. The Board is permitted to render a reasonable inference that the absence of medical evidence and lay complaints referable to a right knee condition is probative evidence that a right knee condition was not likely present in service. See Fountain v. McDonald, 27 Vet. App. 258, 272 (2015) ("[T]he Board must first establish a proper foundation for drawing inferences against a claimant from an absence of documentation."). Nor did arthritis of the right knee manifest to a compensable degree within one year of separation from service. There is no persuasive medical evidence or persuasive credible lay evidence that the Veteran's claimed disorder manifested to a compensable degree within a year of his separation from service or had its onset in service and continued ever since service. Therefore, service connection based on presumptive service connection for a chronic disease or based on a theory of continuity of symptomatology is not warranted. In short, the Board finds that entitlement to service connection for right knee disability is not warranted on a direct basis, on the basis of aggravation, on a secondary basis, or on a presumptive basis based on chronic disability. (Continued on the next page)   The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Elizabeth Jalley, Counsel 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.