Citation Nr: 21066284 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 16-44 459 DATE: October 29, 2021 ORDER Service connection for lumbar strain and degenerative disc disease, lumbar spine (claimed as lower back condition), is denied. Service connection for right hip osteoarthritis, to include as secondary to lumbar strain and degenerative disc disease, lumbar spine, is denied. Service connection for right knee condition, to include as secondary to lumbar strain and degenerative disc disease, lumbar spine, is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran's lumbar spine condition began during active service or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that the Veteran's right hip osteoarthritis began during active service, is otherwise related to an in-service injury or disease, or caused or aggravated by a service-connected disability. 3. The preponderance of the evidence is against finding that the Veteran's right knee condition began during active service, is otherwise related to an in-service injury or disease, or caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for lumbar strain and degenerative disc disease, lumbar spine (claimed as lower back condition), have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for right hip osteoarthritis, to include as secondary to lumbar strain and degenerative disc disease, lumbar spine, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303(a); 3.310(a) 3. The criteria for service connection for right knee condition, to include as secondary to lumbar strain and degenerative disc disease, lumbar spine, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303(a), 3.310(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1969 to September 1969 and from March 1970 to November 1970. This matter comes to the Board of Veterans' Appeals (Board) from a July 2013 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for the Veteran's lumbar strain and degenerative disc disease, lumbar spine (claimed as lower back condition); right hip osteoarthritis; and right knee condition. The Veteran filed a notice of disagreement in July 2013 and perfected his appeal in June 2017. The Board remanded the claim in November 2019 so that the record could be supplemented. Substantial compliance with the remand requests having been achieved, the Board may proceed to consider the claims. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service Connection The Veteran contends that his lumbar strain and degenerative disc disease, lumbar spine (claimed as lower back condition), right hip osteoarthritis, and right knee condition are service connected as the direct result of a back or thigh injury he maintains he suffered while on active duty. In the alternative, he argues that his right hip osteoarthritis and right knee condition are secondary to his lower back condition. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing direct service connection generally requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. 38 C.F.R. § 3.303(b);38 C.F.R. § 3.307(a)(3). Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512. In deciding whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (2007). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1376-77. The Veteran contends he injured his lower back while in active duty in Germany sometime in the fall of 1970. He claims he remembers being transported to the base hospital and being placed on a sheet of plywood covered with a sheet and given muscle relaxers and pain killers. He contends he has had back problems ever since this incident that now include his right hip and right knee. The Veteran's service treatment records (STRs) indicate that at his first induction physical in May 1968, the Veteran did not report any back or hip problems, though he did state that he suffered a "trick knee" and swollen knees in high school. At his first separation examination the following September, the examiner did not find any back, hip, or knee condition. Inducted back into active service in March 1970, his STRs show that he suffered a "charley horse" a muscle spasm is his left thigh in May, causing him to fall and bruise it. The injury was treated with "moist heat" for several days. While there is no record of any particular injury to his lower back, the Veteran's service treatment records do indicate that on or around August 1970, he complained of a low back strain. Two days later he informed doctors that he had been leaning over while unloading boxes and suddenly felt pain in his lower back. He was admitted to the hospital. The medical records reflect that he sought treatment approximately two weeks later because his "mild symptoms" had continued. Treatment providers encouraged him to use a bed board. His separation examination in November 1970 found no abnormalities except for healed brush burn on his lower back. The Veteran noted, in what appears to be in his own hand, "I am in good health," and signed the form. The treatment providers he maintains that he saw in the first several decades after his separation have died, their practices have closed, and their records are unavailable, as the Veteran has repeatedly complained . One other provider, M.S., a chiropractor, has been unable to locate his records. Private medical records before 2007 are therefore unavailable, despite the VA's efforts to obtain them. According to the Veteran, in a letter he filed in January 2013, he suffered back pain throughout the 1970s and 1980s. His private doctor at the time treated the complaints with muscle relaxers and painkillers. He asserts that he underwent a Magnetic Resonance Imaging (MRI) in "the early 80s" that revealed two herniated disks at L-4 and L-5 and that as a result he began using a back brace. The Veteran further related that he began to suffer pain in his right hip and groin area sometime in the 1990s. It was initially diagnosed, he recalled, as a muscle pull, and treated with physical therapy. During one of his therapy session, he claimed, an unnamed therapist suggested that rather than a groin pull the pain may have stemmed from injury to his back caused by "simple wear and tear" due to the way he purportedly walked as a result his back injury. According to the Veteran, in 2003 an MRI of his right hip indicated severe degenerative disease. The MRI disclosed no damage to his left hip. In 2006, the Veteran had a total right hip replacement. The Veteran recounted in 2013 that the surgeon, when asked if his hip condition might be due to his limp, had responded that if the limp were actually overcompensation for his back pain it would "eventually cause problems elsewhere." After a follow-up in November 2007, the private doctor who examined him recorded in his patient notes that the Veteran looked "fantastic," had "excellent motion and strength," and the doctor was happy with his progress. He indicated that he would encourage the Veteran in his exercises and follow-up with another appointment in a year. By March 2009, however, the Veteran reported feeling "exquisite" pain through his lower back and right hip even while sitting. He had 50 degrees of abduction and 90+ degrees of forward flexion in his back. The range of motion (ROM) in his hip was "very good," 90+ degrees flexion, though with a noted grade one weakness. The knee was measured at 90 degrees, with an internal rotation of 25 degrees external and internal rotation of 35 degrees, and a negative straight leg raise. X-rays of the Veteran's back revealed a "lot" of degenerative processes, particularly through the L-4 and L-5 discs of his spine. The doctor noted a little spondylolisthesis. In May 2011, the Veteran sought treatment for pain in his knee that had begun two or three months earlier, though he had not been aware of injuring it. More than 20 chiropractic treatments by the private chiropractor, M.S., and exercise at the direction of a therapist, did not appear to reduce the pain and muscle cramping. The Veteran had an MRI on his right knee in early December 2011. It revealed a tear in the medial meniscus and degeneration of the lateral meniscus that suggested a subtle degenerative tear. During a discussion several days later with his physician about the MRI, he reported that he was "very, very happy" with the results of his 2006 hip replacement and had encountered no problems since. X-rays at the same time revealed some diffuse osteoarthritis changes and medial joint lines spacing narrowing. After reviewing the MRI and X-rays, the doctor offered his opinion that the pain the Veteran was suffering as a result of the medial meniscus tear was exacerbated by a degenerated lateral meniscus, as well as osteoarthritis throughout the knee. They decided to treat the condition with therapy first before attempting to correct it surgically. The treatment included the use of a knee brace and injections of corticosteroids and Orthovisc. In late November 2012, with little improvement, his doctors performed a right knee arthroscopy, partial medial meniscectomy, and extensive debridement. Several weeks later, the doctor opined that the Veteran was "doing well" and suggested that he would continue to follow his progress only if the knee pain continued. In January 2013, M.S., the chiropractor who had treated the Veteran in 2011 and who was unable to find his records of the Veteran's treatment, recounted the Veteran's treatment history in a letter. Clearly incorporating the Veteran's own recollections of his medical history prior to 2011, M.S. offered his opinion that the Veteran's lower back injury in 1970, suffered while he was serving in the Army, had damaged his spine, particularly at the L-4 and L-5 discs, causing them to herniate over time. This weakened the spine and surrounding muscles, he explained, causing the Veteran to alter his gait, which in turn placed "an excessive load" on the right lower extremity, leading to damage to the joints. In short, the back injury caused the degenerative disc disease in the spine, which "flowed through" to the right hip and knee as "secondary to the primary injury." A VA examination in May 2013 showed that the Veteran had limited ROM in his back due to pain from degenerative disc disease, particularly at L-4 and L-5, as indicated in X-rays. He had a negative straight leg raise and no neurological deficits. He occasionally used a back brace or cane but had not brought either with him to the exam. The examiner speculated that he would experience additional limitations during flare-ups or additional repetitive use, but since the Veteran did not suffer a flare-up during the exam, and he had performed the tests repeatedly without apparent additional pain, the examiner could not be certain to what degree. An examination of the Veteran's right hip was conducted the same day. The Veteran himself reported that he had "very infrequent" pain in his right hip and that 2006 hip replacement had improved his hip. The examiner determined that there was some limited ROM due to pain but concluded there was no functional loss or functional impairment and no residuals from the surgery. The ROM was marginally less than that measured by his doctors in 2009, the examiner observed. The Veteran's right knee was also examined. His flexion was measured at 110 degrees, with pain at 100 degrees. Extension of the right knee was normal, as was knee strength, with no medial-lateral instability or subluxation. The examiner detected no residual signs or symptoms due to the 2012 knee surgery, no functional loss or functional impairment, and the Veteran did not use any assistive device such as a brace or cane. The examiner concluded that that it was less likely than not that the Veteran's current back condition was related to an in-service injury or active duty. There was no evidence that a diagnosis of degenerative changes to the thoracolumbar spine was made while the Veteran was on active duty and no evidence of chronicity of signs or symptoms, he explained. Similarly, he opined that it was less likely than not that the Veteran's hip condition was either directly the result of an in-service thigh injury or a secondary result of his lower back injury. He noted that the thigh injury sustained in-service had healed with no evidence of residual complaints or care. As to the "flow through" theory posited by the chiropractor and others, the examiner pointed out that the weight of medical literature does not show a link between one joint being damaged as a result of compensation for damage to another joint. In addition, the examiner had already rejected service-connection for the Veteran's degenerative spinal condition. Finally, the examiner found that it was less likely as not that the Veteran's right knee condition was caused by his lower back condition because there was no nexus established between the two as he had already observed, the weight of medical literature had never proven the mechanism of one joint being damaged by compensation for damage to another joint. In a letter filed in September 2013, a second chiropractor, D.F., offered his opinion for the cause of the Veteran's pain and the necessity for two hip replacements and knee surgery. After reviewing the Veteran's self-reported history and examining the available medical records, D.F. concluded that the Veteran's "original injury to his lumbar spine sustained while in the Army was the precursor to his problems." He speculated that the lumbar MRI in the 1980s "confirmed" herniated discs at L-4 and L-5 levels. Subsequent tests also "confirmed L5 and S1 nerve root compression, radiculitis, and associated muscle weakness in the right lower extremity." This weakness of the muscles of the right lower extremity required the right and left hip replacements and knee surgery, he reasoned, "due [to] associated nerve root compromise." The same month, the Veteran filed a letter "following up" on his appeal of the RO's 2013 decision. He contended that had not reported problems with his lower back during his separation examination because his commanding officer had cautioned him not to report any ailments or his discharge would be delayed and he would be unable to return to the United States. In August 2015, the Veteran sought help from his orthopedist for pain in his left hip. He specifically informed the doctor that he had no issues with his right hip, but complained of pain in his left that had started several months earlier. X-rays revealed a progression of osteoarthritis, with decreased joint space and bone spur formation. After six months treatment, however, his condition grew worse and he underwent a left total hip replacement. In February 2020, the Veteran's back, right hip, and right knee were examined by a VA examiner. The examiner determined that the ROM of the Veteran's back was abnormal, with forward flexion at 0 to 40 degrees, and extension, right lateral extension, and left lateral extension all at 10 degrees limited. Right and left rotation remained within normal range. The examiner noted that pain limited function, though there seemed to be no additional pain when weight-bearing. The Veteran was able to perform repetitive use testing, and the examiner concluded that pain, weakness, fatiguability, or incoordination did not significantly limit the Veteran's function over time. The examiner observed no muscle spasms or flare-up. The veteran's strength was normal, with no muscle atrophy. The straight leg raise test was positive for his right leg, negative for his left. The examiner detected evidence of radiculopathy in mild, intermittent pain and numbness in the lower extremities, involving the L-4 and L-5 and sciatic nerve, but no ankylosis. The Veteran, it was noted, used a back brace occasionally for pain. Reviewing the examination results and the Veteran's medical history, the examiner concluded that the Veteran's lumbar and degenerative disc disease was less likely than not incurred in or caused by his lumbar strain during service. He explained that the medical providers in August 1970 diagnosed an acute lumbar strain without residuals. There was furthermore no chronicity of complaints, symptoms, or care for any back condition until 2011. There was thus no medical nexus between the lumbar strain diagnosed in 1970 and the development of degenerative disc disease diagnosed nearly 40 years later. The Veteran's ROM for his right hip was abnormal: flexion 0 to 55; extension and abduction 0 to 30; and adduction was 0 to 25. He was unable to cross his legs, and external and internal rotation were both only 20 degrees. The examiner noted pain in flexion, abduction, and adduction that caused functional loss. ROM for the left hip was also abnormal: flexion 0 to 50; extension 0 to 30; abduction 0 to 35; and adduction was 0 to 25. External and internal rotation were 0 to 30 and 0 to 35, respectively. Pain was observed at flexion, abduction, and external rotation causing loss of function. He was able to perform repetitive tests for both hips. Pain, weakness, fatigability, and incoordination did not significantly limit functional ability. No loss of muscle strength was detected, no muscle atrophy, and no ankylosis. The examiner found moderately severe residuals of pain, weakness, or limitation of motion as a result of the Veteran's right hip replacement, and no residuals arising from the replacement of the left hip. Imaging studies documented degenerative or traumatic arthritis. The VA examiner concluded that the Veteran's right hip osteoarthritis was less likely than not incurred in or caused by active service. He explained that there had been no complaints or diagnosis of a right hip condition while in service, no complaints or findings of a hip condition at separation, and no complaints of hip pain or problems until 2006, when he was diagnosed with osteoarthritis and underwent a total hip replacement. He attributed the osteoarthritis as most likely due to age-related degenerative changes. During the examination the Veteran denied experiencing pain in his right knee; rather, his complaint was its "intermittent popping." The ROM in both knees was abnormal (0 to 90; 90 to 0) with pain during flexion. There appeared to be no muscle strength loss, muscle atrophy, ankylosis, recurrent subluxation, or joint instability in either knee. He detected residual pain and decreased ROM as a result of the arthroscopic meniscectomy performed in 2012. The examiner determined that the Veteran's right knee meniscal tear post-arthroscopic meniscectomy was less likely than not incurred in or caused by his active service. He observed that there had been no complaints or diagnosis of knee problems or conditions while the Veteran was on active duty, no complaints about his knee at separation, and no evidence of any condition until 40 years later when the tear was repaired. 1. Service connection for lumbar strain and degenerative disc disease, lumbar spine (claimed as lower back condition), is denied. 2. Service connection for right hip osteoarthritis, to include as secondary to lumbar strain and degenerative disc disease, lumbar spine, is denied. 3. Service connection for right knee condition, to include as secondary to lumbar strain and degenerative disc disease, lumbar spine, is denied. The Board finds that service connection for lumbar strain and degenerative disc disease, lumbar spine (claimed as lower back condition); for right hip osteoarthritis, to include as secondary to lumbar strain and degenerative disc disease, lumbar spine; and for right knee condition, to include as secondary to lumbar strain and degenerative disc disease, lumbar spine, are not warranted. The Veteran had few reported physical complaints during his service and none regarding his hips or knees. The two complaints for which he was treated, a bruise to his thigh and a lower back sprain, were treated immediately and he made no follow-up complaints more than two weeks after treatment for either injury. He expressed no complaints at his separation exams; to the contrary, he affirmatively declared that he was in good health during his second and final one. According to the Veteran, he nevertheless suffered back pain throughout the 1970s and 1980s. He was not actually diagnosed with herniated discs at L-4 and L-5 until more than 20 years after separation, however. Furthermore, it was more than 30 years until he was diagnosed with osteoarthritis in his right hip; and more than 35 years until he was diagnosed with a torn meniscus and degenerative disease in his right knee. The pertinent inquiry then is whether the post-service diagnoses were nonetheless related to or could be etiologically linked to his in-service symptoms of a thigh bruise and a back strain. The preponderance of the evidence indicates it could not. The Veteran has been afforded VA medical examinations in May 2013 and February 2020 and neither examiner found the Veteran's lumbar strain and degenerative disc disease, right hip osteoarthritis, and torn meniscus and degenerative disease were etiologically related to his military service. The May 2013 examiner also specifically rejected any secondary connection to either in-service injuries and the Veteran's hip and knee conditions. Both examiners attributed his back, knee, and hip problems to age-related degenerative changes. Alternatively, degenerative hip disease and a torn meniscus are not chronic diseases under Section 3.309(a). See 38 C.F.R. § 3.303(b); 38 C.F.R. § 3.307(a)(3); 38 C.F.R. § 3.309(a). Osteoarthritis is, but there is nothing in the record that shows the Veteran's osteoarthritis was diagnosed during his service or manifested itself within 10 percent or more within one year from the date of separation. See 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Similarly, there is no evidence of a continuity of symptomology; the Veteran did not begin to complain of hip or groin pain until the 1990's, more than twenty years after his separation, and his osteoarthritis was not diagnosed until 2003, more than 30 years later. See 38 C.F.R. § 3.307(a)(3) The VA clinicians set forth the results of comprehensive reviews of the claims file, conducted detailed in-person examinations, and considered the Veteran's lay and expert reports, as well as the results of their own tests and examinations. They provided a clear rationale for their opinions. The VA examiner's opinions are well-explained, based on thorough physical examinations, and an accurate medical history, so are entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("most of the probative value of a medical opinion comes from its reasoning"); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Board has also considered what the Veteran was told by an unidentified therapist in the 1990s and by his surgeon in 2006. Neither opinion, however constituted a specific diagnosis; indeed, both were couched as mere "could be" speculations, and neither were supported by specific references to medical records, tests, medical literature, or a detailed rationale. See Nieves-Rodriguez, 22 Vet. App. at 300-301 (holding that to have probative value, the opinion provider must be fully informed of the pertinent factual premises, provide a fully articulated opinion, and provide a supportive reasoned analysis). The Board has also taken into account the opinion of the Veteran's treating chiropractor M.S. Much of his opinion, however, was based on the Veteran's medical history as related to him by the Veteran, and not from independent records and reports. See Leshore v. Brown, 8 Vet. App. 406, 409 (1995) (mere fact that claimants statements linking disabilities to service are contained in medical report does not render such statements competent medical evidence). Furthermore, the probative value attributed to a medical opinion issued by either VA or private treatment providers to support service connection depends on factors such as thoroughness, degree of detail, and whether there was a complete review of the veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The Board must also consider whether the examining medical provider had a sufficiently clear and well-reasoned rationale, and a basis in supporting objective clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (the Board rejects medical opinions that do not indicate whether the physicians actually examined the veteran, do not provide the extent of the examination, and do not provide supporting clinical data). The Court has held that a bare conclusion, even when reached by a health care professional, is not probative without an accurate factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). M.S.'s explanation of the "flow through" effect of the purported spine injury on the hips and knee - that the injury resulted in a weaking of the muscles in the leg and back, thereby placing an "excessive load" on the right lower extremity, resulting in muscle and joint damage depended upon the conclusion, never sufficiently explained (and rejected by both VA examiners) that the Veteran's back sprain resulted in the development of degenerative disc disease 20 years later. It is also undercut by the fact that the May 2013 the February 2020 VA examiners did not find any evidence of muscle weaking or atrophy in either the Veteran's hips or right knee. Furthermore, as the 2013 examiner observed, the theory is not supported in medical literature. See generally Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (the failure of the physician to provide a basis for his/her opinion may affect the weight or credibility of the evidence in the adjudication of the merits). The Board has also considered the opinion of the consulting chiropractor D.F. His opinion, however, like M.S.'s, relies on the Veteran's recounting of his medical history and fails to explain how the Veteran's back sprain in 1970 led to herniated discs and nerve root compression decades later, and ultimately to degenerative disc disease. See Horn v. Shinseki, 25 Vet. App. 231, 240-42 (2012) ("an unexplained conclusory opinion is entitled to no weight in a service-connection context"). In addition, like M.S., he fails to offer a rationale for how muscle weakness in the Veteran's back resulted in osteoarthritis in the hips and a torn meniscus and degenerative disease in his knee. His hypothesis also fails to account for the VA examiners' findings that there was no muscle weakening or atrophy found in either the 2013 or the 2020 examination. Finally, as the 2013 VA examiner has pointed out, the medical literature does not support the theory. The Board accordingly affords little weight to either opinion. The Veteran himself, of course, maintains that his degenerative disc disease, osteoarthritis in his right hip, torn meniscus and degenerative disease in his right knee are a result, either directly or as a secondary cause, to his injuries in service. While the Veteran's statements are competent to describe his worsening back and hip pain, as the cause of the disabilities involve medical subjects concerning internal physical processes extending beyond an immediately observable cause-and effect relationships, he is not competent to render complex medical opinions regarding etiology of a musculoskeletal disability. He has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Degenerative disc disease, osteoarthritis, and torn meniscus are not the type of conditions that are readily amenable to mere lay diagnosis or probative comment regarding their etiology, as the evidence shows that physical examinations as well as the ability to read and interpret x-rays and MRIs are required to make such diagnoses. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau, 492 F.3d at 1377. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's opinion on this point is non-probative evidence. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d at 1377; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The Board finds the contemporaneous medical evidence, the diagnosis of back, hip and knee conditions decades after separation, and the VA medical opinions to be significantly more probative than the lay and private treatment provider's assertions of record. Hence, the Board attaches significant weight to them. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). (Continued on the next page) As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Accordingly, service connection for lumbar strain and degenerative disc disease, lumbar spine (claimed as lower back condition); for right hip osteoarthritis, to include as secondary to lumbar strain and degenerative disc disease, lumbar spine; and for right knee condition, to include as secondary to lumbar strain and degenerative disc disease, lumbar spine are not warranted. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Wilkinson, Edward L. 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.