Citation Nr: 21070672 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 14-35 374 DATE: November 24, 2021 ORDER Entitlement to service connection for a spine disability, to include as secondary to a service-connected right ankle disability, is denied. Entitlement to service connection for a headache disability, to include as a qualifying chronic disability or undiagnosed illness, is denied. Entitlement to service connection for a right hip disability, to include as secondary to a service-connected right ankle disability, is denied. Entitlement to service connection for a left hip disability, to include as secondary to a service-connected right ankle disability, is denied. Entitlement to service connection left knee disability, to include as secondary to a service-connected right ankle disability, is denied. Entitlement to service connection right knee disability, to include as secondary to a left knee disability or a service-connected right ankle disability, is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that Veteran's spine disability is etiologically related to service or secondary to a service-connected right ankle disability. 2. The preponderance of the evidence is against finding that the Veteran's sinus headaches are etiologically related to his service or is a qualifying chronic disability or undiagnosed illness related to 3. The preponderance of the evidence is against finding that Veteran's right hip disability is etiologically related to service or secondary to a service-connected right ankle disability. 4. The preponderance of the evidence is against finding that Veteran's left hip disability is etiologically related to service or secondary to a service-connected right ankle disability. 5. The preponderance of the evidence is against finding that Veteran's left knee disability is etiologically related to service or secondary to a service-connected right ankle disability. 6. The preponderance of the evidence is against finding that Veteran's right knee disability is etiologically related to service or secondary to a left knee disability or a service-connected right ankle disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a spine disability to include as secondary to a service-connected right ankle disability have not been met. 38 U.S.C. §§ 1112, 1113,1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a sinus headache disability, to include as a qualifying chronic disability or undiagnosed illness have not been met. 38 U.S.C. §§ 1112, 1113,1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for a right hip disability to include as secondary to a service-connected right ankle disability have not been met. 38 U.S.C. §§ 1112, 1113,1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for a left hip disability, to include as secondary to a service-connected right ankle disability, have not been met. 38 U.S.C. §§ 1112, 1113,1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for service connection for a left knee disability, to include as secondary to a service-connected right ankle disability, have not been met. 38 U.S.C. §§ 1112, 1113,1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for service connection for a right knee disability to include as secondary to a left knee disability or a service-connected right ankle disability have not been met. 38 U.S.C. §§ 1112, 1113,1131, 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 in the United States Marine Corps from March 1987 until March 1993. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2018, the Veteran testified before the undersigned Veterans Law Judge during a Board video conference hearing. These matters were previously before the Board in May 2018, November 2020, and April 2021 but were remanded for further development of the records and to obtain adequate VA examinations for the disabilities on appeal. In an August 2021 supplemental statement of the case (SSOC), his claims were denied. These matters are again before the Board for adjudication. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131. 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); 38 C.F.R. § 3.303 (a). Certain chronic diseases, such are arthritis, are subject to presumptive service connection if it manifests to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). VA will also grant service connection on a secondary basis. Service connection on a secondary basis is merited if there is (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Spine disability, to include as secondary to a service-connected right ankle disability The Veteran asserts that his spine disability is related to his training in service consisting of marches and carrying other soldiers on top of their normal ruck sack, ammo, water, chow, weapon, and load bearing vest weights. Alternatively, he contends that it is related to a service-connected right ankle disability. Upon review of the evidence, the Board finds that the preponderance of the evidence is against a finding that his spine disability is etiologically related to service or secondary to his service-connected right ankle disability. The Board concludes that the Veteran has a current diagnosis of degenerative joint disease of the spine as indicated throughout his VA treatment records and VA examinations. However, the Board finds that his service treatment records are silent for any treatment for a back injury or back pain in service. His entrance and separation examination during demonstrated normal clinical evaluation of his spine and he did not endorse having any history of back problems in his report of medical history upon entry to service. Upon separation from service, he underwent a Persian Gulf War Screening in August 1994 and endorsed having medical problems associated with arthritis, his legs/arms, fatigue, stomach, and memory loss. However, he did not endorse having any medical problems related to his "back, neck, shoulder" during the screening. There was no diagnosis of degenerative disc disease of the spine until July 2013. The medical opinions of record also do not support a causal relationship between his spine disability and his military service. Specifically, in a July 2013 VA examiner opined that his back disability was less likely than not related to his military service. The VA examiner indicated that his separation examination was silent for any back condition and that there was no medical evidence after 1993 to establish the evolution and chronicity of a back condition. Specifically, the VA examiner states that a single service treatment record with mention of upper or lower back pain is insufficient medical evidence to establish proximity or causality 20 years later when there are no interim treatment records from 1993 to current. Similarly, a May 2017 VA examiner opined that his spine disability is less likely than not related to his service because his service treatment records were silent for any treatment for a back condition. The May 2017 VA examiner restated that there were no interval findings from the time of discharge in 1993 to the time of the diagnosis of degenerative disc disease and degenerative joint disease of the thoracolumbar spine in July 2013 indicating any evidence of a chronic back complaints over a 20-year time period. The May 2017 VA examiner further added that there was no evidence he endured significant repetitive stress injuries to his lower back based on his reports of long marches with gear and physical training requirements of running. To the contrary, the May 2017 VA examiner states the July 2013 radiological findings of degenerative disc disease are due to the normal aging process. Additionally, the VA examiner states there are no scientific evidence that short-term activities, such as his two to three 25-mile marches with gear, causes degenerative changes because it has not been noted to cause shearing forces or displacement of the spine that would lead to altered biomechanics affecting the spine. While the VA examiner stated that repetitive pull of the trunk musculature could result in increased wear and tear of the discs, the VA examiner stated it would be greater for an individual who limps than for someone with a normal gait. Upon the Board's remand in April 2021, another VA examination was obtained for his spine disability. Consistent with the July 2013 and May 2017 VA examiner's medical opinions, an August 2021 VA examiner further opined that his lumbar spine disability was less likely than not related to military service due to no treatment for a back condition or pain in service. The VA examiner further indicated there is no evidence of chronicity of care either. Based on the foregoing evidence, the Board finds that his spine disability is not etiologically related to service. While his service treatment records reflects that he was seen for other ailments, such as his left knee and ankles, there is simply no complaints or treatment for a back condition or pain in service. This fact weighs against the credibility of any statement that he had a spine condition in service. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013). If the Veteran had a then-existing spine condition, it would be expected that he report it or there be clinical findings of such at the time of discharge. The first indication of a back injury was during a July 2013 VA examination when he was diagnosed with degenerative disc disease of the spine. It was also at the July 2013 VA examination that he first reported injuring his back in 1998 after lifting a child and was put on bed rest for five days by a doctor. The Board has considered the Veteran's lay assertion and belief that his current spine disability was caused by his training in service consisting of marches and carrying other soldiers on top of their normal ruck sack, ammo, water, chow, weapon, and load bearing vest weights. Unfortunately, while the Veteran is competent to report having experienced symptoms of back pain since service, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires medical training and knowledge which the Veteran has not demonstrated. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). The Board acknowledge that the August 2021 VA medical opinion is based on the absence of treatment in service and after. As such, the Board affords minimal probative weight to the August 2021 VA medical opinion. However, the Board affords the most probative weight to the July 2013 and May 2017 VA medical opinions, as the medical opinions were based on consideration of the Veteran's lay assertions and is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Taken together, the July 2013 and May 2017 VA medical opinions establish that the Veteran's spine disability is not at least as likely as not related to an in-service injury, event, or disease, including his participation in long marches carrying heavy gears and other soldiers. Accordingly, as the preponderance of the evidence is against a finding that his spine disability is etiologically related to his military service, he is not entitled to direct service connection. The Board has further considered whether he is entitled to the chronic disease presumption as he has been diagnosed with degenerative disc disease of the spine. However, as indicated above, there is no evidence indicating that he sought treatment for any spine condition or that he was diagnosed with degenerative disc disease within a year after separation from service. Instead, the evidence shows that he was diagnosed with degenerative disc disease in July 2013, 20 years after service. Absent any evidence to the contrary, he is also not entitled to presumptive service connection based on his chronic disability. The Board further finds that the preponderance of the evidence is against finding that his spine disability is proximately caused by or aggravated beyond its natural progression by his service-connected right ankle disability. The Board notes the Veteran was provided with another VA examination in October 2019, but the Board found that the VA medical opinion was inadequate for adjudication purposes in a November 2020 remand. As such, no probative weight is afforded to that VA examination. Following the November 2020 Board remand, a VA examination was obtained in July 2021 to address secondary service connection. That VA examiner opined that his spine disability was less likely than not proximately caused by his service-connected right ankle disability as there is no documentation showing any limping or abnormal gait for a prolonged period of time that would have affected his lumbar spine due to his ankle. His spine disability was also not aggravated beyond its natural progression by his right ankle disability as he did not have a persistent abnormal gait. The VA examiner stated his right ankle condition or right lateral collateral strain is not known to cause or worsen degenerative disc disease of the thoracolumbar. An August 2021 VA examiner also opined that his spine disability is a separate entity entirely from the right ankle disability and is unrelated as a thorough review of medical literature also failed to demonstrate a causal relationship. The VA examiner cites to an online medical article that discuss the causes and symptoms of degenerative disc disease and stated that degeneration may be accelerated by injury, health and lifestyle factors, and possibly by genetic predisposition to joint pain or musculoskeletal disorders. Pertaining to the aggravation factor, the VA examiner could not determine the baseline level of severity but opined that his spine disability was also not aggravated beyond its natural progression by his service-connected right ankle disability. The VA examiner noted he was not diagnosed until July 2013 and was not treated for any back condition in service. There is also no evidence of aggravation of his lumbar degenerative disc disease. Rather, the VA examiner again states his disability is caused by wear and tear of the spinal discs and that discs naturally tend to dry out and lose their support function. The Board has considered the Veteran's assertion that his spine disability is secondary to his service-connected right ankle disability. However, he has not demonstrated any specialized knowledge or expertise to indicate he is capable of rendering a competent medical opinion. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Accordingly, the Board finds the July 2021 and August 2021 VA medical opinions to be more probative because they are based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Ultimately, the Board finds that the preponderance of the evidence is against finding that his spine disability was etiologically related to service or secondary to his service-connected right ankle disability. As such, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, his claim for entitlement to service connection for his spine disability is denied. 2. Sinus headache condition, to include as a qualifying chronic disability or undiagnosed illness The Veteran asserts his sinus headaches is related to service as it began after he returned from the Persian Gulf. VA will pay compensation to a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that (1) became manifest during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016; and (2) by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (a)(1). A "qualifying chronic disability" means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service-connection. 38 C.F.R. § 3.317 (a)(2)(i). Here, the Veteran's military personnel records reflect he participated in Operation Desert Storm in Saudi Arabia from February 1991 to March 1991. As such, he has qualifying service. However, he does not have a qualifying chronic disability contemplated under 38 C.F.R. § 3.317. Although he testified at the Board hearing that he is unsure what caused his headaches, a July 2013 VA examiner noted he had a diagnosis of sinus headaches and that it was a condition with clear and specific etiology and is not a condition related to specific exposure event experienced by veterans during service in Southwest Asia. Notably, in a March 2018 VA treatment record, a VA doctor noted his sinus headaches are fairly controlled as long as he used nasal spray and takes Loratadine. An August 2021 VA examiner further indicated that he had a diagnosis of chronic rhinosinusitis with symptoms including headaches. Based on the foregoing evidence, the Board finds that the Veteran's sinus headaches have been clearly diagnosed and is related to his chronic rhino-sinusitis diagnosis. As such, he is not entitled to a Gulf War Presumption. Notwithstanding the foregoing presumptive provision, the Veteran is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, F.3d 1039, 1042 (Fed. Cir. 1994). Upon review of the evidence, the Board finds that the preponderance of the evidence is against finding that his sinus headache disability is etiologically related to his military service. The Board concludes that he has a current diagnosis of sinus headaches as indicated in a July 2013 VA examination. Moreover, his service treatment record shows treatment for headaches in the left frontal temporal region for a week. He was assessed with a probable frontal sinusitis versus cluster headaches, but follow-up visits indicates that he was ultimately diagnosed with cluster headaches as opposed to frontal sinusitis. However, the Board finds that the medical opinion of record does not establish a causal relationship between his sinus headache disability and service. In a July 2013 Gulf War examination, a VA examiner opined that his sinus headaches were less likely than not related ot service. While the Veteran was treated for headaches in November 1987, the VA examiner stated that there were no other mention of headaches in his service treatment records or at separation. As such, his single episode of headache was more likely than not an acute and transitory condition which revolved without residuals. The VA examiner further noted that there were no medical evidence or objective findings that supports he had a chronic headache condition beginning during service that required ongoing treatment, management, and evaluation. He was provided with a VA examination in January 2021 was obtained to determine the etiology of his sinus headache disability. However, in an April 2021 remand, the Board found the January 2021 VA medical opinion to be inadequate because it did not specifically address the etiology of his sinus headache disability. As such, little to no probative weight is afforded to the January 2021 VA examination. Following the April 2021 Board remand, an August 2021 VA examiner opined that his sinus headache disability was less likely than not related to his military service. The VA examiner's rationale is that he has a diagnosis of chronic rhinosinusitis which includes his symptoms of headaches and that he has no separate diagnosis for chronic sinus headaches. The VA examiner states his service treatment records were silent for any diagnosis or treatment for sinusitis and that his November 1987 treatment for headaches were ultimately diagnosed as cluster headaches. His separation examination was negative for any sinus condition to include sinus headaches and his 1994 Persian Gulf War Registry examination did not document any sinus related headache concerns. His October 1994 post-service treatment records at a VA facility in West Palm Beach also did not document a past medical history of sinus related headaches. The VA examiner also considered his lay statement that his sinus headaches began after his return from the Persian Gulf but essentially stated there were no clinical evidence found to support his statement. While the Veteran believes that his current sinus headaches are related to service, as a lay person, he has not shown that he has specialized training sufficient to render such an opinion. 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). In this regard, the diagnosis and etiology of a sinus headache disability are matters not capable of lay observation and require medical expertise to determine. Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's own opinion regarding the etiology of his current sinus headaches complaints is not competent medical evidence. Rather, the Board finds that the medical evidence of record does not relate the Veteran's headache disability to his service but rather to his chronic rhino-sinusitis condition. To the extent he believes his sinus headaches are secondary to his chronic rhinosinusitis condition, his chronic rhinosinusitis condition has not been service-connected. To this end, a claim for secondary service connection is not warranted on that basis. In sum, after reviewing the pertinent lay and medical evidence, the Board finds that the preponderance of the evidence weighs against the claim. As such, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Therefore, the Board finds that service connection is not warranted for the Veteran's sinus headaches disability. 3. Right hip disability, to include as secondary to a service-connected right ankle disability 4. Left hip disability, to include as secondary to a service-connected right ankle disability The Veteran further asserts his right and left hip disabilities are related to Marine Corps training consisting of marches and carrying other soldiers on top of their normal ruck sack, ammunition, water, chow, weapon, and load bearing vest weights. Alternatively, he asserts that his right and left hip disabilities are secondary to his service-connected right ankle disability. Upon review of the evidence, the Board finds that the preponderance of the evidence is against finding that his right and left hip disability is etiologically related to service. The Board concludes that the Veteran has been diagnosed with mild degenerative changes of his left and right hip as indicated in a May 2017 VA examination and August 2020 computed tomography (CT) scan. His May 2017, January 2021, and August 2021 VA examination also reflect a diagnosis of bilateral trochanteric pain syndrome. With regards to an in-service event, his service treatment records are absent for any treatment for a left hip disability. As to his right hip, the Board notes that a May 2017 VA examiner noted that a January 1993 service treatment record noted "right hip." However, the VA examiner indicated that there were no other details provided to explain that entry. The Board's review of his service treatment records also does not reveal any additional treatment for a right hip condition. Further review of his post-service treatment records, to include an August 1994 Persian Gulf War registry does not reflect any reports of a right or left hip condition or pain. The Board has further considered the Veteran's lay statements of record that he was required to do multiple full combat load hikes in preparation for their MC readiness evaluation and that having to run 20 miles affected his hips. See November 2012 Statement in Support of Claim and December 2014 Correspondence. While it is reasonably accepted that the Veteran engaged in these activities based on a review of his military personnel records and service treatment records, the Board finds that the medical evidence supports a causal relationship between his hips and activities during service. As an initial matter, the Board notes that he was provided with a VA examination in January 2014, but no opinion was provided. He was also provided with a VA examination in October 2019, but the Board found that the October 2019 VA medical opinion lacked an adequate rationale in a November 2020 remand. Nonetheless, a May 2017 VA examiner opined that his right and left hip disabilities were less likely than not etiologically related to service. Aside from the single right hip entry in January 1992, his service treatment records did not reflect any hip injuries in service and that there were no hip conditions noted at separation. The VA examiner further stated there were no interval findings from the time of his separation to the time of his bilateral trochanteric bursitis and mild degenerative changes until 20 years after service. Of significance, the VA examiner stated there were no evidence that he endured any significant repetitive stress injuries to his hips based on his subjective reports of long marches with gears and running and that there is no scientific evidence that those types of short-term activities are causes of his degenerative changes. Rather, the VA examiner indicates that his current radiological findings are more likely than not due to the normal aging process. Additionally, an August 2021 VA examiner opined that his left and right hip disability were less likely than not related to his service. Pertaining to his left hip, the VA examiner's rationale also referenced the absence of any treatment in service or after service and that there was no evidence demonstrating chronicity of care. Instead, the VA examiner noted that it was not until November 2012 that he first mentioned having left hip pain. With regards to his right hip disability, the VA examiner stated that his right hip pain in service was acute, that there was no evidence of chronicity of care, and that his symptoms were subjective only. The VA examiner ultimately concludes that there is no evidence that his degenerative arthritis of his right hip began in service. The Board has considered the Veteran sincere belief that his right and left hip disability is related to his participation in long marches, running, and carrying other soldiers on top of their normal ruck sack, ammunition, water, chow, weapon, and load bearing vest weights. However, he has not shown that he has specialized training sufficient to render a medical opinion in this matter. 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). In this regard, the Board affords the most probative weight to the May 2017 and August 2021 VA medical opinion as they are based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As such, the Board finds that the Veteran is not entitled to direct service connection for his left and right hip disability. The Board has further considered whether he is entitled to the chronic presumption. However, as discussed above, his VA treatment records and VA examinations does not demonstrate a diagnosis of degenerative arthritis of his hips until a May 2017 x-ray finding, more than 20 years after service. As such, the Veteran is not entitled to the presumption for chronic disease. The Board further finds that the preponderance of the evidence is against finding that his left and right hip disabilities are secondary to his service-connected right ankle disability. While a January 2021 VA examiner did not specifically provide a medical opinion as to whether the Veteran's left and right hip disability were proximately caused by his service-connected right ankle disability, the VA examiner adequately addressed the aggravation factor. Specifically, the January 2021 VA examiner stated his right ankle condition would not have led to increased strain on the right hip. The VA examiner stated there is not more weight bearing on the injured leg and that the joints are not adjacent. Of importance, the VA examiner stated there is a lack of evidence of a limp or abnormal gait for a prolonged period of time that would have affected the left hip due to the ankle condition. The VA examiner further opines that there is a lack of medical evidence showing his hips were aggravated beyond its natural progression as an October 2019 x-ray demonstrated his hips were normal. As to his diagnosis of greater trochanteric pain, the VA examiner stated that the disability is chronic and can remain for years but that there was no evidence showing it has been aggravated beyond its natural progression. In an August 2021, a VA examiner opined that his right and left hip disability were less likely than not proximately due to his service-connected right ankle disability. Pertaining to the left hip disability, the VA examiner stated there is no clear evidence upon review of orthopedic literature (Wheeless' Textbook of Orthopedics) that an injury to one joint could significantly impact another or opposite uninjured joint or limb unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than five centimeters such that it results in altered gait pattern to the extent that there is obvious Trendelenburg gait. The VA examiner concluded that level of severity was not supported based on a review of his records, history, and examination. While it is not unusual for two joints to share properties in the same person, the VA examiner stated that one joint disease does not spread to another or cause damage to it. As to his right hip disability, the VA examiner stated his right hip arthritis is a separate entity entirely from the right ankle disability is unrelated and that review of medical literature fails to establish a causal relationship. The August 2021 VA examiner further opined that there is no evidence showing an aggravation of his left hip and right hip disability as the medical literature does not support a relationship between a right lateral collateral ligament strain aggravating left hip arthritis. Instead, the VA examiner referenced an online medical article indicating that common triggers of an osteoarthritis flare are overdoing an activity, trauma to the joint, bone spurs, stress, repetitive motion, cold weather, a change in barometric pressure, an infection, or weight gain. While the Veteran believes that his right and left hip disability were caused by his right ankle disability, the Board finds that he is not competent to render a medical opinion as to the etiology of his right and left hip disability. 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). Unfortunately, the Board affords the most probative weight to the May 2017 and August 2021 VA medical opinion as they are based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As such, entitlement to secondary service connection is not warranted. In sum, the Board finds that the preponderance of the evidence is against finding that his right and left hip disability is etiologically related to service or to his service-connected right ankle disability. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine but finds that the doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Left knee disability, to include as secondary to a service-connected right ankle disability 6. Right knee disability to include as secondary to a left knee disability or a service-connected right ankle disability The Veteran further seeks service connection for his right and left knee disability. Specifically, he asserts that he first injured his knee in service and began having right knee pain shortly after. Specifically, he asserts that his right knee disability is secondary to his left knee. The Veteran also believes that his bilateral knee disabilities are related to in-service training consisting of marches and carrying other soldiers on top of their normal ruck sack, ammunition, water, chow, weapon, and load bearing vest weights. Alternatively, he asserts that his right and left knee disabilities are secondary to his service-connected right ankle disability. Upon review of the evidence, the Board concludes that he has a diagnosis of degenerative arthritis of both knees as evidenced in a May 2017 x-ray and VA examination. However, the Board finds that the preponderance of the evidence is against finding that the Veteran's right and left knee disability is etiologically related to his service. The Board finds that the Veteran's service treatment records reflect he was treated for left knee pain in February 1988 and was diagnosed with a lateral collateral ligament strain. However, there is no evidence demonstrating any treatment for a right knee condition during service e. His post-service treatment records, to include his August 1994 Persian Gulf War registry, also do not reflect any reports of a right or left knee medical condition. Subsequent VA treatment records from 1994 through 2000 also does not reflect any treatment for a right or left knee condition. In May 2017, a VA examiner opined that his bilateral knee disabilities were less likely than not related to his service. The VA examiner indicated he was not treated for any right knee condition during service. While he was treated for his left knee, the VA examiner stated that condition was an acute and isolated event which did not require any additional treatments. Even considering that he filed a claim for service connection for a left knee disability, the VA examiner stated that his physical examination and radiological findings were normal at that time. The VA examiner indicated there were no interval findings from the time of discharge in 1993 to the time of the diagnosis of right patellofemoral pain syndrome of right knee in July 2013. Rather, the VA examiner states that the current radiological exam findings were more likely than not due to the normal aging processes. Notably, the VA examiner stated there were no significant repetitive stress injuries to his knees based on his subjective report of long marches with gear and running and that scientific evidence does not support that those short-term activities cause degenerative changes. The Veteran was additionally provided with a VA examination in November 2019 and January 2021. However, the VA examiners did not provide a medical opinion for direct service connection. As such, upon the Board's April 2021 remand, a VA examination was obtained to address whether his right and left knee disabilities were etiologically related to service. Thereafter, an August 2021 VA examiner also rendered a medical opinion against his claim stating that his right and left knee disabilities were not etiologically related to his service. Like the May 2017 VA examiner, the August 2021 VA examiner stated his left knee pain during service was acute, that there was no evidence of chronicity of care, and that his symptoms were subjective only. The VA examiner further noted his separation examination was silent for any knee complaints. Moreover, there was no evidence suggesting his right knee pain began in service or that there was any evidence of chronicity of care. As such, no nexus has been established for his right knee. The Board has considered the Veteran's lay assertion that he injured his left knee in service and that his left and right knee disabilities are related to marches and carrying other soldiers on top of their normal ruck sack, ammunition, water, chow, weapon, and load bearing vest weights. However, he has not demonstrated any specialized knowledge or expertise to indicate he is capable of rendering a competent medical opinion. Although lay persons are competent to provide opinions on some medical issues, as to the specific issue in this case, the etiology of right and left knee disabilities falls outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Taken together, the Board finds the May 2017 and August 2021 VA examiner's opinion pertaining to direct service connection to be most probative as it is based on a thorough review of his service treatment records and post-service treatment records and takes into consideration the Veteran's lay assertions. The May 2017 and August 2021 VA medical opinions are also supported by a clear rationale. Based on the foregoing evidence, the Board finds that direct service connection is not warranted for his right and left knee disabilities. The Board further finds he is not entitled to presumptive service connection based on a chronic disability. While he has a current diagnosis of degenerative arthritis of his right and left knee, the preponderance of the evidence is against finding that his degenerative arthritis manifested within a year following separation. While he filed for VA disability for his left knee disability in November 1994, there is no medical evidence showing that he was diagnosed with degenerative arthritis at that time. It was not until May 2017, more than 20 years after service, that the Veteran was diagnosed with degenerative arthritis of the right and left knee. As such, presumptive service connection for degenerative arthritis of his right and left knee is not warranted. The preponderance of the evidence is also against finding that his right and left knee disability are secondary to his service-connected right ankle disability. The Board notes the Veteran was provided with a VA examination in November 2019, but the Board found that VA medical opinion to be inadequate for adjudication purposes in a November 2020 remand. Upon remand, a VA examination was obtained in January 2021. While that VA examiner did not diagnose the Veteran with degenerative arthritis of his knees, the VA examiner did note a diagnosis of patellofemoral pain syndrome. To that extent, the VA examiner opined that his condition was not aggravated by his right ankle disability as it would not have led to increased strain on the right knee and that there would not be more weight bearing on the painful extremity. Furthermore, the VA examiner noted there is a lack of evidence of a limp or abnormal gait for a prolonged period of time that would have affected either knee due to the ankle condition. The VA examiner further stated his right and left knee disability were not aggravated beyond its natural progression as there is no diagnostic evidence of abnormalities of the knees. Specifically, the VA examiner indicated that October 2019 x-ray showed normal knees. An August 2021 VA examiner also opined that his right and left knee disability was less likely than not proximately caused or aggravated by his service-connected right ankle disability. In support of the medical opinion, the VA examiner restates that there is no evidence in orthopedic literature that an injury to one joint could significantly impact another or opposite uninjured joint or limb unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than five centimeters such that it results in altered gait pattern to the extent that there is obvious Trendelenburg gait. The VA examiner further states that the medical literature does not support a relationship between his right and left knee disability being aggravated by a right lateral collateral ligament strain. Again, the VA examiner cites to an online medical article which indicates that triggers for osteoarthritic flares are from overdoing an activity or trauma to the joint, bone spurs, stress, repetitive motions, cold weather, barometric pressure changes, an infection, or weight gain. Again, the Board has considered the Veteran's lay statements regarding a causal relationship between his right and left knee disability and his service-connected right ankle disability. However, the Board maintains that he is not competent to render a medical opinion as to the etiology of his disabilities. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Absent any evidence to the contrary, the Board affords the most probative weight to the January 2021 and August 2021 VA medical opinion as it is supported by a review of his treatment records and is supported by a detailed and clear rationale. To the extent that the Veteran believes his right knee disability is related to his left knee, as discussed in this decision, his left knee disability has not been service-connected. As such, secondary service connection is not warranted. (Continued on the next page) Based on the foregoing evidence, the Board finds that the preponderance of the evidence is against finding that his right and left knee disability is etiologically related to his service or service-connected right ankle disability. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine but finds that it is not applicable in the instant appeal. As such, his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Xiong, 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.