Citation Nr: 21003315 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 13-15 854 DATE: January 21, 2021 ORDER Entitlement to service connection for lumbar-spine disorder is denied. Entitlement to service connection for cervical-spine disorder is denied. Entitlement to service connection for left-knee disorder is denied. FINDINGS OF FACT 1. The objective medical evidence shows lumbar-spine disorder is not caused by an event, injury, or illness during active service, nor did arthritis manifest to a compensable degree within one year of separation from active service. 2. The objective medical evidence shows cervical-spine disorder is not caused by an event, injury, or illness during active service, nor did arthritis manifest to a compensable degree within one year of separation from active service. 3. The objective medical evidence shows left-knee disorder is not caused by an event, injury, or illness during active service, nor did arthritis manifest to a compensable degree within one year of separation from active service. CONCLUSIONS OF LAW 1. The criteria for service connection for lumbar-spine disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2019). 2. The criteria for service connection for cervical-spine disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2019). 1. The criteria for service connection for left-knee disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Marine Corps from September 1976 to May 1984. In September 2013, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These matters were remanded in August 2018. They have been returned to the Board. An August 2020 rating decision granted service connection for left-wrist disorder, effective May 24, 2010. That claim, originally part of this appeal, is therefore no longer before the Board. Service Connection Generally, service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for a disability requires evidence of: (1) The existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). See also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996). Certain chronic diseases may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. That period is usually one year. 38 C.F.R. § 3.307 (a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303 (b). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing and in-service disease or injury and a nexus for chronic diseases is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303 (b). 1. Entitlement to service connection for lumbar-spine disorder. 2. Entitlement to service connection for cervical-spine disorder. The service treatment records (STRs) show the Veteran presented in September 1977 with shooting pains in his neck and back. The Veteran reported his medical history of a previous fracture of vertebrae in the spring of 1974 (during the Veteran’s high-school years), when falling from a high-bar during gymnastic exercises. He wore a collar for the next 8 months. He complained of intermittent neck numbness and added that since that time he experiences repeatedly pain in the neck, but it has recently increased. On physical and neurological examination, upper extremities were “completely” within normal limits. In November 1977, the Veteran complained of weakness of the left hand, with no paresthesias. He further complained of a stiff neck after reading. The treatment provider’s impression was “C6, 7, 8 Radiculopathy ??” and he made reference to a finding involving C6 in the spring of 1974 (pre-active service). He recommended proceeding with electromyograph/nerve conduction studies. In January 1978, the Veteran was examined and assessed the Veteran with “back strain.” The Veteran presented with neck pain in August 1978, with stiffness and limited range of motion. The treatment provider’s impression was cervical myositis. In September 1978, the Veteran requested medication, as he was experiencing cervical spasms. In a follow-up visit, the treatment provider noted the Veteran’s 4-year history of cervical pain with no relief with any treatment. He further noted the Veteran’s report of spasms and numbness. Although x-rays were negative, the Veteran exhibited tenderness with any motion of the neck. In February 1982, the Veteran complained of intermittent neck pain, with intermittent loss of strength and loss of sensation, after picking up his son the night before and feeling sudden pain and loss of strength. The treatment provider noted a history of neck pain which began in “1976” after a fall (probably referring to the 1974 high school gymnastics injury), in 1977 during active service, when turning his head, but also when the Veteran attempted to lift a 200-pound weight sometime between 1978 and 1979 regarding which the treatment provider appears to have noted “traction,” and in December 1981, possibly concerning a “car.” He had an electromyogram/verve conduction test at some point. In March 1982, the Veteran again presented with neck pain radiating to his left-upper extremity. The treatment provider gave a provisional diagnosis of C7-8 radiculopathy. Examination on the first visit showed no pain, paresthesias or weakness “at this time.” On examination, the Veteran’s upper-extremity strength was 5/5 bilaterally and sensory responses were intact. Pulses were “ok.” With hyper abduction of the neck , without tenderness, spasms deformity or crepitus. An x-ray revealed loss of height at C7-C6, but otherwise within normal limits. The treatment provider’s impairment was intermittent neck pain and paresthesias. He prescribed bed rest, pain medication and heat. In the follow-up visit, the Veteran reported shooting pain bilaterally and left-hand numbness, with paresthesia. The treatment provider assessed the Veteran with neck strain. It appears from the Veteran’s September 2013 the Board hearing testimony that, at this point, he was being treated at a hospital in Bethesda, Maryland and prescribed a neck collar. The third-visit treatment note in February 1982 indicates that by this time the Veteran had been prescribed a neck collar, on the removal of which the Veteran exhibited pain. However, the treatment provider also noted, “improvement.” Later in February 1982, the Veteran presented for a neurosurgical examination, during which the above history of neck pain was noted. The provisional diagnosis was cervical strain for 5 weeks. In a March 1982 follow-up visit, the treatment provider found intermittent pain radiated to the 3rd, 4th and 5th digits. Although last seen for cervical pain in March 1982, the Veteran presented in December 1982 for refill of medications for cervical strain. The treatment provider assessed him with recurrent cervical spasm. In February 1984, the Veteran presented with complaints of low-back pain after lifting a couch the previous day. Although, on evaluation, he did not appear to be in acute distress, the treatment note shows instructions that he be transported by ambulance to a hospital on a nearby Air Force base for admission. Examination revealed limited range of motion of the back, with pain and compression of the sciatic notch, but not the sciatic nerve root. The treatment provider assessed the Veteran with low-back strain, with sciatica. On March 2, 1984, the Veteran presented with complaints of neck pain, with stiffness radiating to the right shoulder and arm to the elbow, after turning his head the day before, hearing a “pop” and feeling sharp pain in his neck to his right arm. He added that movement that day was restricted in any direction and, on examination, range of motion maneuvers of flexion and lateral flexion were limited to 15 – 20 degrees and lateral rotation to 10 – 15 degrees. X-rays revealed findings within normal limits, with some straightening. The treatment provider assessed the Veteran with muscle contraction and prescribed valium and heat application. However, the STRs from this date through what appears to be the last entry on April 18, 1984 show no further reports or complaints by the Veteran regarding the cervical spine. The May 1984 separation examination shows the spine and “other musculoskeletal” were found to be normal, although the Veteran reported past or current recurrent back pain. The post-service record shows in July 2000, the Veteran presented for private treatment with complaints of left-shoulder pain. Among other findings on examination, the treatment provider found the Veteran had no cervical muscle spasms, he had full range of motion of the cervical spine without pain or tenderness, no crepitation, and, other than the left shoulder, “[h]e has no other area of complaint.” In July 2001, the Veteran underwent a general physical examination for maintaining his commercial driver’s license in the state of Pennsylvania, which show entries of “NL” (for normal) for spine and make no mention of reports by the Veteran of cervical-spine or lumbar-spine disorders. After falling from the steps of his truck in April 2003, resulting in severe low-back pain and difficulty walking, between March and July 2003, the Veteran underwent private treatment physical therapy, noted as due to decreased functional ability, during which the Veteran’s medical and physical therapy diagnosis was noted as “[n]euritis or radiculitis, unspecified of thoracic or lumbosacral region.” Findings included radiating lumbar back pain, exacerbated by repetitive bending or stooping and sitting for an extended period, then standing to an erect posture. A May 2003 MRI revealed degenerative disc disease at L4-5 and L5-S1. The Veteran was also diagnosed with “radiculitis - cervical,” findings of which included “lower segment syndrome,” with burning and radiating, exacerbated by any activity and lifting one or more pounds with the left-upper extremity. The Veteran visited his private treatment provider, Dr. J.M.T. in June 2003, to whom he reported chronic low-back pain over the sacral region, sharp pains down the back of his leg, described as burning, shooting, sharp, stabbing, numbing, and accompanied by weakness and spasms in the lower back. He added that the pain is worse with prolonged sitting, walking, standing, and lifting. Dr. J.M.T. noted what is presumably the May 2003 lumbar MRI showing a degenerative disc at L4 and L5-S1. On examination, cervical range of motion was noted a “fair.” Dr. J.M.T. diagnosed the Veteran with flexional tractional injury in April 2003, with left S1-radiculopathy with an extrusion of L5-S1 disc material focal on the S1 root. Later in June 2003, Dr. J.M.T. again noted that the Veteran has left-S1 radiculopathy. In November 2003, the Veteran was independently evaluated by Dr. D.M.B., an orthopedic surgeon, whose findings confirmed S1-radiculopathy and whose conclusion was the Veteran could not return to his job as a commercial truck driver. Records of Dr. P.A.K. from April 2003 through May 2004, associated with the Veteran’s Social Security claim, show the Veteran’s reports of lumbar pain with radiating numbness. He was assessed variously with acute lumbar-spine strain and low-back pain, both with radiculitis or left-lower-extremity radiculitis. Between January 2004 and March 2005, Dr. J.M.T. administered at least 5 lumbar transforaminal epidural injections at S1. In a February 2004 follow-up visit, he found an extradural defect at L5-S1 in a position to impact the S1 nerve root. The Veteran reported persistent S1 sensory complaints, although improving after the recent injection. Additionally, an x-ray revealed multi-level degenerative changes, with spondylosis from C4-5 to C6-7 and C7-T1, as well as C7 radicular findings after the Veteran’s recent fall. He recommended physical therapy sessions. A February 2005 cervical MRI revealed spondylitic disease at the cervical thoracic junction, a right-disc herniation at C6-7 and upper cervic spondylitic disease. In visits to his private treatment provider, Dr. P.A.K. throughout 2005, the Veteran at times reported neck pain. In the period of VA treatment between 2010 and at least August 2020, progress notes show treatment for lumbar pain and degeneration of lumbar or lumbosacral intervertebral discs. Prescriptive treatment included a back brace, mechanical traction, a static pelvic home traction unit, and heat application. Cervical stenosis treatment also included a home traction unit and heat application. X-rays for both disorders overall indicated stability. VA outpatient notes in April 2013 indicate the Veteran was treated for both lumbar and cervical disorders with a TENS (transcutaneous electrical nerve stimulation) unit and morphine. Chiropractic care at VA in September 2016 produced the following impression/diagnosis: “1. Cervical spine pain (chronic). 2. Cervical radiculitis into the left upper extremity. 3. Mild C4-C5, mild to moderate C5-C6, and moderate C6-C7 degenerative disc disease. 2. Significant multilevel osseous neural foraminal narrowing as described. 4. Lower back pain (chronic). 5. Stable appearance of the lumbar spine with mild grade 1 anterolisthesis of L4 on L5 and mild degenerative disc disease at L4-L5.6. Lumbar radiculitis into the left lower extremity.” In a comprehensive assessment of the Veteran’s lumbar and cervical-spine disorders, the treatment provider concluded, “At this time, I would not recommend any Chiropractic care. There is nothing I can offer him by way of Chiropractic care.” He recommended current MRIs and treatment at the VA pain clinic, as well as at some point he would need a second opinion from the neurosurgery department. The treatment provider discussed with the Veteran the potential risk/benefits of chiropractic treatment options, including spinal adjustments, mobilization, manual therapies and therapeutic modalities, as well as alternative treatment options and the option of no treatment. However, the Veteran declined chiropractic care. In May 2019, the Veteran underwent a VA examination for thoracolumbar spine, in which the examiner stated 2003 diagnoses of lumbar spondylosis with radiculopathy and lumbar-disc disease with radiculopathy. He noted in the Veteran’s medical history that his lumbar-spine disorder claim was initially denied in 2010 due to no chronic condition being diagnosed in service (just some acute episodes) and private records showing a job-related injury to the lower back in 2003. In addition to noting that the Veteran’s separation examination was silent as to musculoskeletal complaints or disorders, in reviewing the Social Security disability evaluation in June 2006, he noted that it states the back problems started in April 2003 when the Veteran had his fall from his truck. He further noted that an independent medical evaluation of November 2003 noted the Veteran denied any prior low-back pain or any pre-existing condition before his April 2003 accidental fall. At the present VA examination, the Veteran reported constant ache with occasional spasms, stiffness and pain at 5-7/10. The VA examiner noted that the Veteran has had no other surgery, injections, chiropractor treatment, or brace for the back. Testing revealed overall intact strength, reduced ranges of motion, reduced sensory responses, signs of moderate radiculopathy in the lower extremities, intervertebral disc syndrome (IVDS), and available imaging studies documented arthritis. The May 2019 VA examiner opined that lumbar-spine disorder was as less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. He explained that the STRs show only 3 widely separated incidents of being evaluated for back pain, for which there is no evidence that they are related or produced chronic symptoms. He added, “His separation physical is silent for any back problem. There are no records available until about 2000. CDL [commercial driver’s license] physicals in 2000 and 2001 are silent for any back problem and he was fit for driving. He worked rather physical jobs of cabinet making, commercial fishing and truck driving after leaving service until his back injury in 2003. Several records appear to report that the veteran was in good health and had no previous back problems until the April 2003 injury. It is less likely than not that the veteran’s back conditions are related to service.” In the May 2019 VA examination for cervical spine, the same VA examiner stated 2004 diagnoses of cervical-disc disease with radiculopathy and cervical spondylosis with radiculopathy. He noted the Veteran’s reports of daily pain in the posterior neck, left side worse than the right. The Veteran reported aggravating factors as turning the head left, downward and upward gaze, reaching up, quick movements, carrying, lifting, bending, cold, damp weather, and wearing a helmet or backpack. Testing on examination revealed reduced ranges of motion and moderate levels of radiculopathy, as well as IVDS. Available imaging studies documented arthritis. The May 2019 VA examiner opined that cervical-spine disorder was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. He explained in his rationale that, although the Veteran experienced approximately 5 in-service neck evaluations, “these appear to be separate, unrelated incidents that resolved on their own. His separation physical is silent for any neck problem. There are no records available until about 2000 which then show he was fit for his CDL physicals to drive commercially. The first neck symptoms or conditions appear to be around the same time as his fall on his back at work in 2003. Since then he has had neck problems. There is not enough medical evidence to make a link to service.” Although there is a record of treatment in service for low-back sprain and neck pain, there is no evidence of permanent residual or chronic disability in the STRs or indicated by evidence following service. The above summary of the medical evidence shows in the post-service period that both lumbar-spine disorder and cervical-spine disorder were not reported by the Veteran or treated until after the Veteran’s April 2003 accident, in which he fell from the steps of his truck on to his back. For example, the July 2001 physical examination for his commercial driver license (CDL) show normal findings for spine, the examination was silent for any reports of back or neck disorders and the Veteran was found fit for driving. As noted in the May 2019 VA examination thoracolumbar spine, several records contain reports that the Veteran was in good health and had no previous back problems until the April 2003 accident. Lastly, arthritis is included among chronic diseases eligible for presumptive service connection under 38 C.F.R. § 3.309 (a). Numerous treatment records for both lumbar and cervical-spine disorders show degenerative findings, indicating arthritis, and most notably both May 2019 VA examinations show available imaging studies had documented arthritis. However, the record offers no evidence of the manifestation of arthritis to a compensable degree within one year of separation from active service. Additionally, because it was never identified in service or directly after, and putting aside the lack of medical evidence of treatment for hearing loss at that time, it would be otherwise impossible to establish continuity of symptomatology based on the identification of symptoms during, directly after or continuing for a longer period after active service. Consequently, the presumption of service connection for arthritis, as associated with lumbar and cervical-spine disorders, as a chronic disease, is not available to the Veteran. For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claims for service connection for lumbar-spine disorder and cervical-spine disorder. 3. Entitlement to service connection for left-knee disorder. The STRs show in the May 1984 separation examination that the Veteran’s lower extremities were found to be normal. Additionally, the Veteran denied past or current “trick” or locked knee. After separation from service, although the Veteran presented with complaints of his left knee feeling “loose,” an August 2010 VA x-ray revealed a normal left knee. In the period from August 2010 through at least August 2020, the Veteran was followed for left-knee pain and left-knee osteoarthritis. VA outpatient notes in April 2013 indicate that the Veteran was using a brace or, in the alternative, a sleeve for his left knee. He reported intermittent swelling and occasional buckling. In the May 2019 VA examination for knee and lower leg conditions, the VA examiner stated a 2010 diagnosis of left-knee strain. He noted the Veteran’s reports of daily variable pain in the anterior/medial knee, a pain level of 2-3/10 to 5-6/10, occasional swelling, locking, giving way, and painful crepitus. The Veteran reported aggravating factors as mounting and descending steps, cold, damp weather, increased use, walking on hard surfaces, wearing “hard” shoes, some lifting and carrying, twisting, squatting, and kneeling. The VA examiner noted the Veteran has had no surgery or acupuncture, but had had an injection once with only mild improvement. Testing on examination showed overall reduced left-knee ranges of motion, but intact strength, and no instability. However, available imaging studies did not document arthritis. The May 2019 VA examiner opined that left-knee disorder was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. In his rationale, he first observed there is no record of a left-knee injury being evaluated or treated during service, the separation examination is silent for any knee condition and there are no medical records available until 2000. He added, “CDL physicals in 2000 and 2001 do not record any left knee condition. He now has some chronic left knee strain but this is many years after leaving service and there is no significant medical evidence linking the left knee condition to service. Although the medical evidence shows continuous treatment at VA between 2010 and 2020 for left-knee pain and osteoarthritis, nothing in the evidence of record overall supports a causal connection with active service. Additionally, the record offers no evidence of the manifestation of arthritis to a compensable degree within one year of separation from active service and, for the same reasons stated in the preceding section, continuity of symptomatology based on the identification of symptoms during, directly after or continuing for a longer period after active service cannot be established and the presumption of service connection for associated arthritis as a chronic disease is therefore not available to the Veteran. For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection for left-knee disorder. Turning to the Veteran’s lay evidence, the Board has carefully reviewed and considered the Veteran’s September 2013 Board hearing testimony, as well as his numerous reports to treatment providers, as they appear throughout the record. The Board acknowledges that lay persons are competent to report symptoms which impact their senses, events they observe and the drawing of certain inferences and there is no reason otherwise to doubt their credibility. However, although it is error to reject categorically a lay person as competent to provide a nexus opinion, not all questions of nexus are subject to non-expert opinion. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Whether a lay person is competent to provide a nexus opinion depends on the facts of the particular case. In Davidson, the United States Court of Appeals for the Federal Circuit (Federal Circuit) drew from an earlier decision to explain its holding. In that earlier decision, the Federal Circuit stated the following: “Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Federal Circuit provided an example, stating that a lay person would be competent to identify a simple condition such as a broken leg, but not competent to provide evidence as to a more complex medical question, such as a form of cancer. Id. at n.4. Also of note, it was the United States Court of Appeals for Veterans Claims (the Court) which explained that non-expert witnesses are competent to report that which they have observed with their own senses, as already mentioned above. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Taking Davidson, Jandreau and Layno together, the complexity of the question and whether a nexus opinion could be rendered based on personal observation are factors in determining whether a non-expert nexus opinion or diagnosis is competent evidence. Looking first to the Board hearing, the Veteran testified that lumbar-spine disorder began in service as a result of physical contact during hand-to-hand combat instruction, as well as due to the excessive weight of carry gear throughout his career in the Marine Corps. He attributes the cervical spine disorder also to hand-to-hand combat instruction and the left-knee disorder to the stress of carry the weight of gear. However, as shown in the above summary, in his in-service presentations in 1977 and 1978 for neck pain, the Veteran himself reported fracturing vertebrae in 1974, when in high school, during gymnastic maneuvers on the high bar. Additionally, sometime in 1978 or 1979, he reported he felt neck pain when he attempted to lift a 200-pound weigh during gym exercise. When presenting again in February 1984 for low-back pain, the Veteran specifically reported it occurred after lifting a couch the day before. Additionally, there is no in-service record of complaints, treatment or diagnosis for left-knee disorder. It does not appear in the record until 2010, in VA treatment notes. Overall, each in-service complaint of lumbar and cervical spine pain, including those reported in the Veteran’s Board hearing testimony as due to hand-to-hand combat training, appears to be separate and distinct, each received treatment, but did not receive ongoing treatment or therapy, indicating each injury in fact resolved. Significantly, the Veteran himself testified that, after the injury to his neck, he re-enlisted in the Marines, with no findings on examination or reports by the Veteran to prevent his re-enlistment. At the conclusion of all active service, the May 1984 separation examination showed no reports of lumbar and cervical injuries and normal findings overall for musculoskeletal body-segments. Moreover, as already stated above, in a July 2000 examination for the Veteran’s left shoulder, the treatment provider, after stating findings of no cervical spasms or limited motion, added, “He has no other area of complaint.” The April 2003 emergency room note, written 6 hours after the Veteran’s fall from his truck, notes the Veteran’s account of his fall and he “states that he has been having pain since then” (emphasis added). Records of Dr. P.A.K. from April 2003, after the accident, through May 2004 consistently address the Veteran’s reports of low-back pain. However, the record from January 2002 through April 2003, before the accident, make no mention of reports by the Veteran of back pain, but rather address the Veteran’s left-shoulder disorder and other concerns. Additionally, in November 2003, when the Veteran underwent an independent physical evaluation, apparently for work purposes, Dr. D.M.B., after noting the Veteran’s medical history and after his own physical examination, stated in his report, “there does appear to be a causal relationship to accident of 4/13/03 [when The Veteran fell from the steps of his truck], which is well documented in the medical records and he’s had persistent back and leg pain ever since, which again is well documented by multiple caregivers.” He added, “The patient denies any pre-existing conditions. Certainly if he has seen physicians or had low back pain in the past, these have not been made aware to me [sic]….” Dr. D.M.B’s statements suggest that the Veteran’s reports to him are inconsistent with the Veteran’s subsequent assertions, in testimony and to treatment providers, that his lumbar disorder is directly attributable to an injury while he was instructing during active service and the Board thusly will conclude that such a disparity in reporting his medical history is, at the very least, problematic for the Board. The Veteran’s testimony, without clinical support shown in the record as to pain and limited motion beginning in service and continuing thereafter or, as just shown above, with awkward and unresolved contradictions, leaves no more than the suggestion that the lumbar, cervical and left-knee disorders were caused by or incurred in active service and therefore only the belief of the Veteran as a lay person that a certain legal conclusion should be reached. The Veteran is competent to report he experienced the pain and limited motion associated with each disorder. However, the inferences he has drawn from what he experienced and observed fall outside the realm of his competency. The record does not indicate he possesses the highly specialized education, training and clinical experience to be able to identify the origins, causes and distinctions in pathology relating to what he felt in the course of experiencing separate and distinct injuries involving the same body-segment. The Veteran’s inference of causation is therefore not competent evidence but, rather, surmise. Nonetheless, the Veteran’s lay evidence must in turn be weighed against other evidence, as all relevant evidence of varying kinds must be considered. For the reasons stated, the Board ascribes greater probative weight to the examination findings and opinions of the May 2019 VA examiner, as they were rendered by a medical professional after objective review of the medical evidence of record and in-person examination of the Veteran. Moreover, they display a thorough knowledge of the Veteran’s medical history and their conclusions have exhibited consistency and sound clinical judgment. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). (Continued on the next page)   The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claims, the doctrine is not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Franke, Associate 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.