Citation Nr: 21064285 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 09-43 827 DATE: October 19, 2021 ORDER Entitlement to compensation under the provisions of 38 U.S.C. § 1151 for bilateral lower extremity peripheral polyneuropathy, claimed as due to medication prescribed by the VA, is denied. Entitlement to service connection for a bilateral knee disability is denied. FINDINGS OF FACT 1. There is no competent and probative evidence of the Veteran incurring additional disability that was proximately caused by carelessness, negligence, lack of proper skill, or error in judgment on VA's part following prescribed Amlodipine. The noted transient edema resolved with proper and timely discontinuation of the medication, and peripheral neuropathy is unrelated to the transient edema or the prescribed medication. 2. The preponderance of the evidence is against finding that the Veteran's bilateral knee disability had its onset during service or is otherwise related to it. CONCLUSIONS OF LAW 1. The criteria for compensation under the provisions of 38 U.S.C. § 1151 for bilateral lower extremity peripheral neuropathy are not met. 38 U.S.C. § 1151; 38 C.F.R. §§ 3.361. 2. The criteria to establish service connection for a bilateral knee disability are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1962 to December 1965. This appeal was remanded by the Board in August 2013, March 2017, May 2020, and April 2021. The appeal has since returned to the Board for further appellate consideration. Bilateral Lower Extremity Disability Under the Provisions of 38 U.S.C. § 1151 In pertinent part, section 1151 provides for compensation for qualifying additional disability in the same manner as if such additional disability were service- connected. A qualifying additional disability is one in which the disability was not the result of the Veteran's willful misconduct; and, the disability was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran; and, the proximate cause of the disability was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or was the result of an event not reasonably foreseeable. 38 U.S.C. § 1151. To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a Veteran's additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the Veteran's additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care, medical or surgical treatment, or examination without the Veteran's informed consent. In determining whether additional disability exists, the physical condition immediately prior to the disease or injury upon which the claim for compensation is based will be compared with the subsequent physical condition resulting from the disease or injury. Compensation will not be payable for the continuance or natural progress of diseases or injuries for which the hospitalization or treatment was authorized. 38 C.F.R. § 3.361(b). It is also necessary to show that additional disability actually resulted from such disease, or that an injury or an aggravation of an existing disease or injury was suffered as a result of hospitalization or medical treatment and is not merely coincidental therewith. The mere fact of aggravation, alone, will not suffice to make the disability compensable in the absence of proof that it resulted from disease or injury or an aggravation of an existing disease or injury suffered as a result of training, hospitalization, medical or surgical treatment, or examination. 38 C.F.R. § 3.361(c)(1), (2). Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Informed consent is the freely given consent that follows a careful explanation by the practitioner to the patient of the proposed diagnostic or therapeutic procedure or course of treatment. The practitioner must explain in a language understandable to the patient the nature of a proposed procedure of treatment; the expected benefits; reasonably foreseeable associated risks, complications or side effects; reasonable and available alternatives; and anticipated results if nothing is done. 38 C.F.R. § 17.32. The patient or surrogate must be given the opportunity to ask questions, to indicate comprehension of the information provided, and to grant permission freely without coercion. The practitioner must advise the patient or surrogate if the proposed treatment is novel or unorthodox. The patient or surrogate may withhold or revoke his or her consent at any time. The informed consent process must be appropriately documented in the medical record. 38 C.F.R. § 17.32(d). Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). Analysis The Veteran asserts that the diagnosed bilateral lower extremity neuropathy resulted from prescribed Amlodipine at the VA. For the reasons expressed below, the Board finds that the claim must be denied. During a September 2010 VA examination, the Veteran reported total numbness of all toes up onto the bilateral feet at the mid-metatarsal area. An EMG revealed polyneuropathy. The examiner explained that this was different than radiculopathy and was often associated with conditions such as alcohol use and diabetes. The examiner noted that in this case, the Veteran reported a history of alcohol use. A December 2010 VA treatment record noted that the Veteran was allergic to Amlodipine, which caused edema. In February 2011 statements, the Veteran indicated that he never claimed his neuropathy was secondary to his lumbar spine disability but rather that it resulted from Amlodipine prescribed by VA. In November 2014, a VA examiner opined that the Veteran's transient lower extremity edema and resulting peripheral neuropathy symptoms were at least as likely as not caused by Amlodipine. The examiner explained that based on review of the record and the Veteran's lay assertions, the edema and sensory deficit resolved after he was instructed to stop taking Amlodipine. Specifically, in May 2011, he denied having numbness or tingling in the lower extremities. The examiner concluded that the Veteran had transient neuropathic symptoms that resolved after he stopped taking Amlodipine with no residual effect, which was expected once the "offending" medication was stopped. There was no evidence of a current chronic disability due to Amlodipine at the time of this examination. The examiner further opined that the transient lower extremity edema and resulting peripheral neuropathy were less likely than not the result of negligence on the part of the VA. The examiner reasoned that any medication could have a side effect and the fact that the Veteran suffered transient symptoms from Amlodipine was not an example of negligence, incompetence, or poor treatment on the part of VA. Amlodipine is a generally safe medication that was on the market for decades. It was also in common usage and was not considered a risky usage choice in most patients. More importantly, there was nothing in the Veteran's record prior to prescribing Amlodipine that would have indicated the medication could not be used. He had a side effect that was not permanent, which resolved as soon as the physician stopped the medication. Lastly, the examiner noted that if the Veteran were to have ongoing edema and/or neurologic symptoms, it would be less likely than not due to Amlodipine because he no longer took it. According to December 2014 VA treatment records, the Veteran had numbness and tingling in both feet since taking Amlodipine in 2009. The Veteran indicated that the swelling resolved after he stopped taking the medication but that the tingling and numbness continued, and at times, he felt like his feet were "dead." In the February 2015 notice of disagreement (NOD), the Veteran stated that he was told by a VA neurologist that Amlodipine could cause neuropathy but that it was very rare (less than 1%). He added that he still suffered from severe neuropathy. In May 2015, the Veteran underwent a VA peripheral nerves condition examination, at which time the examiner confirmed a diagnosis of bilateral upper and lower extremity peripheral polyneuropathy. This examiner noted the Veteran's reports regarding symptoms associated with Amlodipine but only addressed the upper extremities explaining why a diagnosis of upper extremity neuropathy was not warranted. In September 2017, the Veteran underwent an additional peripheral nerves condition examination, at which time it was noted that he took Amlodipine for about one to one and half months in 2010, at which time his feet became swollen. After stopping the medication, the swelling subsided but he was later diagnosed with peripheral neuropathy. The neurologist opined that the peripheral neuropathy was due to the use of Amlodipine but was not due to carelessness nor negligence of the prescriber because such side effects were extremely rare. The neurologist indicated that Amlodipine allergy test was not practical and that he never performed one. In April 2019, the Veteran underwent an additional peripheral nerves examination and in a January 2020 addendum opinion, the examiner, a physician opined that it was less likely than not that the Veteran's peripheral neuropathy became worse or was caused by the prescribed Amlodipine. The examiner reasoned that the Veteran reported numbness in the feet and legs "x years as of 2010," and as such, since Amlodipine was prescribed in 2009, the numbness predated. The EMG that revealed polyneuropathy was conducted months after the Veteran stopped taking Amlodipine, and medical literature showed no evidence of adverse reaction progressing months after discontinuation of the medication. The examiner added that the conclusion was that this Veteran's neuropathy was idiopathic and developed coincidental to Amlodipine use, but not due to it. The examiner further opined that the additional disability had not resulted from carelessness, negligence, lack of skill, or similar incident of fault on the part of the attending VA personnel. The examiner reasoned that the peripheral neuropathy developed independent of any VA action or inaction. The neuropathy resulted from an event that could not have reasonably been foreseen by a reasonable healthcare provider because it spontaneously developed unrelated to any other identified condition/treatment. There was also no failure on the part of VA to timely diagnose and/or properly treat the claimed disease or disability, which allowed the disease/disability to continue to progress because the was no cure to peripheral neuropathy and not treatment that limited to alter its course. In other words, peripheral neuropathy will continue to progress regardless of treatment. Lastly, the examiner indicated that just because the Veteran first noticed symptoms after taking Amlodipine did not mean there was a causal relationship between the two, and the fact that some people were allergic to it does not mean an allergy test should have been conducted. Regarding the literature cited by the 2014 examiner, this examiner explained that such did not state a cause and effect between Amlodipine and peripheral neuropathy but rather just discussed symptoms reported by people who took the medication. In March 2020 correspondence, the Veteran submitted a February 2020 article that showed 0.07% of patients who took Amlodipine had peripheral neuropathy. The article did not discuss whether the medication was the cause of the neuropathy but provided statistical data such as age and gender of affected people. In January 2021, the Veteran underwent an additional peripheral nerves conditions examination. After a review of the claims file and examination of the Veteran, a neurologist opined that the Veteran's peripheral neuropathy was less likely than not due to use of Amlodipine in 2010, as this medication rarely caused neuropathy. Other causes of neuropathy could have been related to gastrointestinal disturbances, history of parathyroidectomy, and also being idiopathic. Regarding the conflicting medical evidence, this neurologist agreed with the 2014 examiner's indication that less than one percent of people using Amlodipine could develop neuropathy, which meant that it was less likely than not related to the prescribed medication. Due to the conflicting evidence, the Board obtained an additional June 2021 addendum opinion. The neurologist noted that the essence of this case was that the Veteran was placed on Amlodipine by his primary care physician at the VA. The medication was prescribed for hypertension on May 14, 2009 and was first dispensed in June 2009. It expired or was stopped a year later in the summer of 2010. The neurologist added that there was a confusion in the record as to when the medication was stopped. The Veteran stated that it was stopped after several weeks in August 2009 but per VA records he was taking it late into 2010 without edema being seen. It was around August 2010 that the Veteran stated he stopped the medication due to edema. The September 2017 examination report noted that edema began in July 2010 and that the medication was stopped in August. He had edema with Amlodipine for only a few weeks per his own statements. The neurologist noted that the Veteran may have been on Amlodipine for about 12 months if he was taking it the whole time, with the terminal 4 to 8 weeks associated with edema. The neurologist noted that the records confuse the 2009/2010 timeline, but the VA records showed a current prescription that was stopped in the summer of 2010. The neurologist noted that no notes could be found stating that the Veteran contacted his primary care physician when he decided to stop the Amlodipine. The neurologist further noted that the Veteran had neuropathic and radicular pain prior to stopping the Amlodipine; and after stopping the medication, the edema improved/went away but the neuropathic pain persisted. The timeline of the edema and its resolution are not in the record but perpetuated, provider by provider based on the Veteran's history. The neurologist concluded that although no information could be found, Amlodipine was known to cause edema, and as such, the Veteran's statements are accepted. The neurologist then opined that the Amlodipine did not cause the bilateral lower extremity peripheral neuropathy. The neurologist explained that the Veteran was prescribed the medication in May 2009, picked up in June 2009, had no edema documented by medical personnel in 2009 or even into 2010, and was stopped after a few weeks of edema in the summer of 2010. In this regard, the examiner noted that the Veteran clearly had lower extremity neurologic symptoms for years prior to the exposure to Amlodipine and prior to the development of edema. He had several orthopedic issues. The neurologist further explained that the numbness and tingling was consistent with peripheral neuropathy and was symmetric, while the weakness was asymmetric and inconsistent with peripheral neuropathy. Rather, the weakness was consistent with orthopedic issues. He did not have autonomic neuropathy, and such was not expected from bilateral lower extremity edema. Regarding the edema, the neurologist explained that this was a common side effect for all calcium channel blockers and Amlodipine was in that class. If edema happens, the drug is stopped, as was with this Veteran. In this regard, the neurologist explained that while edema was an annoying side effect of Amlodipine, it was not an allergic reaction. This was an important distinction because taking a drug continuously when allergic was dangerous but taking a drug and tolerating side effects was another issue. The neurologist explained that such was very common with this kind of medications. The neurologist further added, "I don't like antidotes, but I have never been taught nor have heard that when a patient develops a drug induced edema, we neurologists must IMMEDIATELY AND QUICKLY stop that drug, or the patient will develop a PERMANENT NEUROPATHY." The neurologist stated that in connection with this case, most recent medical literature was reviewed, which did not even mention edema especially not transient edema. If this was the case, many drugs would have a "boxed warning" or a "black box warning" about such. In other words, while Amlodipine was an edema causing drug, no data linking edema to a permanent neuropathy was found. Extensive number of articles about amlodipine and edema fail to mention peripheral neuropathy as complication. The examiner provided examples from the literature of situations where complications occurred and explained why those were distinguished from this Veteran's edema. Similarly, the neurologist opined that Amlodipine could not in itself cause the peripheral neuropathy. Edema was a side effect not an allergic reaction and as such could not trigger neuropathy. Such reactions were life threatening, easily diagnosed, and not present in this Veteran. The neurologist added that the only thing that made sense in this Veteran was that the edema did indeed cause nerve irritation of a pre-existing neuropathy that the Veteran was not aware of or did not report. The peripheral edema was transient and while transiently present may have caused distal sensations that were more evident to the Veteran, edema could cause nerves to tingle indeed. However, these then went away when the edema went away as stated by the Veteran while his perception of the peripheral neuropathy continued. The neurologist indicated that the most likely cause of the peripheral neuropathy was a combination of issues including age, but also his gout, kidney stones, and general medical situation with hypertension. All of these along with alcohol could contribute to it. The neurologist concluded that bottom line was that, more likely than not this was "idiopathic" or age-related peripheral neuropathy, which was much less likely related to transient Amlodipine and its resulted edema. The neurologist further opined that the Veteran had transient edema that went away and was not considered an additional disability but rather just an annoying side effect that could not be ignored. Here, it was not ignored, the Veteran did the right thing and stopped taking the medication after several weeks of the edema, exactly what any physician would have done. There was no evidence that the Veteran contacted any physician regarding the edema to get advice, which was not answered. Regarding the literature discussing allergic reaction to Amlodipine, the examiner again explained that this Veteran had no allergic reaction. As such, an allergy test would not have predicted the edema or the peripheral neuropathy. Such test was not done by anyone prior to prescribing such drugs. Furthermore, while the record did not show whether the Veteran was warned about certain side effects, the neurologist indicated that no physician writes a list of all possible side effects, although he was sure some was discussed on some level. However, even if such was not done, the occurrence of transient drug induced edema that resolves upon discontinuation was not an injury or a damage. It was "transient," unpredictable, and handled appropriately by stopping the drug. The neurologist further opined that drug side effects as in this case and even drug allergies were unpredictable. There were rare situations where allergic testing may be indicated prior to prescription or ingestion but that had nothing to do with this case. Here, the side effect was handled correctly by stopping the medication. Based on the evidence, the Board finds that the preponderance of the competent and credible evidence demonstrates that the Veteran did not incur additional disability as a result of the treatment she received at the VA. As the Veteran did not sustain additional disability as a result of VA medical treatment, service connection under 38 U.S.C. § 1151 cannot be established. As explained by the 2021 neurologist, the edema was a transient side effect that did not develop into an actual disability and the peripheral neuropathy was unrelated to the few weeks of edema that resulted from taking Amlodipine. Although the Veteran believes that his peripheral neuropathy was caused by the prescribed Amlodipine, as noted above, the edema was a common side effect, and the drug was stopped in a timely manner. The medical evidence is against finding that the Amlodipine was the cause of the Veteran's peripheral neuropathy. To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case-by-case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Here, the Board finds the Veteran's lay assertions extends far beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. The Board adds that, under the facts of this case, the Veteran is not competent to opine that he sustained any additional disabilities because that is a medical question that requires medical expertise, which he is not shown to possess. Moreover, while medical professionals agreed that the transient edema was the result of the medication, no medical professional opined that such caused the peripheral neuropathy. His assertions in this regard are not considered competent medical evidence and are therefore afforded no probative weight. The Board finds the specific, reasoned opinions of the trained health care providers, specifically the 2021 neurologist, who reviewed the evidence and provided well-reasoned opinions to be of greater probative weight than the general lay assertions of the Veteran. The Board further finds that no permanent disability was demonstrated as being due to VA medical care. In this regard, the Board finds that the medical evidence the most probative and such evidence demonstrates that the Veteran did not have an additional disability resulting from VA medical care. Lastly, in the absence of evidence of additional disability due to VA medical treatment, the question of alleged VA negligence is rendered moot. That is, in the absence of an additional disability due to VA medical care, the question of negligence and (un)foreseeability did not need be reached. A claimant bears the evidentiary burden to establish all elements necessary to support the claim, which based on the evidence discussed above, was not done in this case. Regardless, however, as discussed above, even if the edema were to be considered a disability, such was transient in nature, and addressed properly by stopping the medication. Based on the foregoing, as the preponderance of the evidence is against the claim for compensation benefits pursuant to 38 U.S.C. § 1151, the benefit-of-the-doubt rule is does not apply, and the claim must be denied. Service Connection Applicable Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110; 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Arthritis is a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) for "chronic" in-service symptoms and "continuous" post-service symptoms apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For a showing of a chronic disease in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. 38 C.F.R. § 3.303(b). Continuity of symptomatology after service is required where a condition noted during service is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. Id. The presumptive service connection provisions based on "chronic" in-service symptoms and "continuity of symptomatology" after service under 38 C.F.R. § 3.303(b) have been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013) (holding that the "chronic" in service and "continuous" post-service symptom presumptive provisions of 38 C.F.R. § 3.303(b) only apply to "chronic" diseases at 3.309(a)). If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic' disease became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. A claimant bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give an appellant the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107(b)). Analysis The Veteran generally asserts that he believes his bilateral knee disability is the result of training during active duty service. The Veteran has current diagnoses of right and left knee disabilities. See e.g., March 2015, April 2019, and July 2021 examination reports. However, for the reasons expressed below, the Board finds that service connection is not warranted. The Veteran's service treatment records are silent for any complaints, treatment, or diagnosis of right and/or left knee disability. During the October 1965 separation examination, the lower extremities were noted as normal. The Veteran denied having trick or locked knee. In 1970, the Veteran filed claims for service connection but failed to mention any right or left knee problem. It was not until 1999 that private treatment records showed the Veteran's complaints of bilateral knee pain that bothered him for "a period of time." He did not mention any in-service injury at the time. In November 2007, the Veteran filed a claim for service connection for a twisted right knee but did not mention a left knee problem. He did not identify any specific in-service injury. In a January 2009 statement in support of claim, the Veteran indicated that it was actually both knees that bothered him, which he believed was due to squat jumps and duck walks in basic training. He reiterated the same in May 2009 and February 2010 statements in support of claim. According to VA treatment records dated in 2009 and 2014, the Veteran continuously complained of knee pain. Neither the Veteran nor a medical professional mentioned military service in relation to the knee treatment. In March 2015, the Veteran underwent a VA knee compensation examination, at which time the examiner rendered diagnoses of right knee meniscal tear and bilateral degenerative arthritis and calcium pyrophosphate deposition disease. All with an onset date of approximately 2000. The Veteran reported that the onset of his pain was approximately 10 years earlier but added that he believed it was related to duck walking, deep knee bends, and squat jumps during service. He recalled having knee pain and burning sensation during service but did not recall pain at separation from service or shortly after service. After review of the claims file and examination of the Veteran, the examiner opined that the bilateral knee disability was less likely than not related to service. The examiner reasoned that during this examination the Veteran denied experiencing any knee problems at separation from service or shortly after but rather pain that began 10 years prior to this examination. The examiner added that no statement indicating the Veteran had ongoing knee pain since service was found, and a review of the medical record showed treatment beginning decades after service. The examiner explained that the disabilities diagnosed were common and supported this assertion by citing to medical literature. In April 2019, the Veteran underwent an additional knee compensation examination, at which time the examiner confirmed diagnoses of right knee meniscal tear, bilateral degenerative arthritis, and bilateral calcium pyrophosphate deposition disease. The Veteran stated that he believed these conditions were related to military training. After a review of the record, the examiner, a nurse practitioner, opined that the bilateral knee disabilities were less likely than not related to service. The nurse practitioner reasoned that the condition during service was acute only with no evidence of chronicity of care. In July 2021, the Veteran underwent an additional knee compensation examination, at which time the examiner redarned diagnoses of bilateral arthritis and non-gout crystalline arthropathy. The examiner noted that the medical records supported the onset of pain around 1999 with subsequent right knee arthroscopy in 2002. When asked, the Veteran reported no injuries to his knees or treatment during service but recalled some pain during service and no treatment until approximately 1999. After review of the record and examination of the Veteran, the examiner, an orthopedic sports medicine and orthopedic surgery physician, opined that it was less likely than not that the diagnosed knee disabilities were related to service. The physician reasoned that during service the knee pain was acute only with no evidence of chronicity and subjective symptoms only. The physician added that although the Veteran reported experiencing transient knee pain while exercising during service, the treatment records, to include the separation examination, were silent for any complaints or treatment for a right/left knee disability. The available treatment records post-service showed that the first treatment was approximately three decades after separation from service without specific injury. The examiner further explained that the diagnosis of pseudogout was unrelated to exercise but rather to crystal deposition within joints and therefore unrelated to the Veteran's military service. Regarding the diagnosis of patellofemoral arthritis, the physician explained that this was more likely than not typical age-related joint degeneration with no evidence of an injury during service and not treatment for almost 30 years after separation. Lastly, the examiner noted that during the discussion with the Veteran, he reported that he thought this portion of his claim had been dropped, and that he did not recall any injury to his knees while in service but only could recall pain while performing exercises. The examiner concluded that such pain was acute and transient and would not be expected to produce any structural injury to the knees. After a careful review of all the evidence, lay and medical, the Board finds that the Veteran's bilateral knee disability was not incurred in service, and symptoms of arthritis of the knees were not chronic in service or continuous since service, or manifested within one year of separation. As noted, arthritis is a "chronic disease" and as such is subject to consideration of presumptive service connection. Here, due to the lack of medical evidence, there is no competent objective evidence to show that the Veteran's bilateral knee arthritis manifested to a degree of 10 percent within one year after separation from service. Specifically, arthritis was not shown until decades after separation from service. Moreover, to the extent the Veteran suggests that symptoms of the currently diagnosed bilateral knee disability were continuous since service, such assertions are internally inconsistent and not credible. As discussed in detail above, the Veteran's service treatment records no reports of any knee problems during service or at the time of separation. Notably, the Veteran filed a claim for compensation in 1970, so if he had a knee disability at that time it follows that as he was demonstrably aware of the claim process and would have filed a claim of entitlement to service connection for a bilateral knee disability at that time if he had such disability. Moreover, the medical treatment records in 1999 and subsequently did not indicate that the onset of pain was over three decades earlier during service. The Veteran did not report and the evidence does not show any complaints or treatment prior to 1999, decades after separation from service. The mere absence of medical records does not contradict a Veteran's statements about his symptom history. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In this case, the Veteran's more recent statement implying his knee pain had its onset in service are contradicted by past medical records, where no knee complaints were documented. See AZ v. Shinseki, 731 F.3d 1303, 1318 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); Kahana, 24 Vet. App. at 440 (Lance, J., concurring) (citing Fed. R. Evid. 803(7) for the proposition that "the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded"). The approximately three decades period without problems since discharge weighs against the claim. The Veteran's failure to report any complaints of right/left knee pain prior to, at most, 1999 is persuasive evidence that he was not then experiencing any relevant problems and outweighs his more recent recollection to the contrary. To the extent that the Veteran asserts otherwise when filing this claim, the Board finds those assertions made for VA compensation purposes are not credible because they are contradicted and outweighed by the more contemporaneous lay and medical evidence, including the Veteran's own statements when he sought treatment for knee problems in 1999 during which time he indicated that the knees bothered him for "a period of time" but made no reference to pain since service or chronic pain. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (finding that a Board decision properly assigned more probative value to a private hospital record that included lay history that was made for treatment purposes than to subsequent statements made for compensation purposes). The Board is not implying that the Veteran purposely gave contradictory statements; it may merely be that with the passage of time his recollections were not entirely accurate. For these reasons, service connection on presumptive basis is not warranted. The Board also finds that the claim is not warranted on a direct basis. While the Veteran asserted that his knees disabilities are related to service, he is a lay person, and while competent to relate observable symptoms such as pain, he is not competent to relate a medically complex musculoskeletal disorder to his military service, as he does not possess the requisite medical knowledge, training, or experience to do so. Moreover, a mere conclusory generalized lay statement that a service event or illness caused the claimant's current condition is insufficient to establish medical etiology or nexus. Waters v. Shinseki, 601 F.3d 1274 (2010). On the contrary, all medical professionals who treated the Veteran did not even mention an in-service injury. Moreover, the 2021 orthopedic surgeon considered the Veteran's lay reports about ongoing knee pain but explained that the bilateral knee disability was less likely than not related to service. This opinion was demonstrably fully informed of the pertinent factual premises of the case and provided a fully articulated opinion with supporting reasoned analysis explaining why the Veteran's bilateral knee disability was not related to active duty service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Notably, the Veteran provided no medical evidence to support a relationship between service and his diagnosed bilateral knee disability. (Continued on the next page) Accordingly, the Board finds that the evidence weighs against finding that the Veteran's bilateral knee disability is causally or etiologically related to service; therefore, the appeal is denied, and the benefit-of-the-doubt doctrine does not apply. L. Chu Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Yaffe, 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.