Citation Nr: 21071722 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 16-04 676 DATE: December 1, 2021 ORDER Entitlement to a rating in excess of 10 percent for a right knee disability prior to January 8, 2020, and in excess of 40 percent thereafter, is denied. Entitlement to service connection for a lumbar spine disability is denied. FINDINGS OF FACT 1. Prior to January 8, 2020, the Veteran's right knee disability was productive of extension limited to 12 degrees. 2. After January 8, 2020, the Veteran's right knee disability was productive of extension limited to 40 degrees. 3. The preponderance of the evidence is against finding that a lumbar spine disability was caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for a right knee disability prior to January 8, 2020 have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.159, 3.102, 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, DC 5260, 5261. 2. The criteria for a disability rating in excess of 40 percent for a right knee disability after January 8, 2020 have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.159, 3.102, 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, DC 5261. 3. The criteria for entitlement to service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1968 to October 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal of June 2015 and April 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In a July 2021 rating decision, service connection for a left knee disability was granted. This represents a full grant of the benefits sought, and the issue is no longer in appellate status. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). The record contains no indication that the Veteran has disagreed with the initial rating or effective date assigned, thus, those matters are not in appellate status. See Grantham, 114 F. 3d at 1158 (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). Increased Evaluation The Veteran's right knee limitation of extension is rated as 10 percent disabling under Diagnostic Code 5261 prior to October 24, 2017. From October 24, 2017 to January 8, 2020, the Veteran's right knee is rated as 10 percent disabling under Diagnostic Code 5260 for painful motion. Among other rating criteria, VA's rating schedule includes eight diagnostic codes applicable to evaluating knee and leg disabilities and several diagnostic codes related to arthritis of the musculoskeletal system. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5263, 5010, and 5003. During the pendency of the appeal, the criteria for evaluating musculoskeletal disorders were revised, effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, and 5257 VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the Veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. VA thus must consider the claim for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, even though the amended regulations are not substantially different from the prior versions and would not result in a different outcome, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria as of February 7, 2021. With respect to the applicable Diagnostic Codes to the Veteran's knee disabilities, Diagnostic Codes 5003, 5010, and 5257 were revised, not materially, and will be discussed below. Diagnostic Codes 5260 and 5261 were not revised and will be noted immediately below. Under Diagnostic Code 5260, limitation of flexion of the leg warrants a noncompensable evaluation when flexion is limited to 60 degrees; a 10 percent evaluation when limited to 45 degrees; a 20 percent evaluation when limited to 30 degrees; and a 30 percent evaluation when limited to 15 degrees. Under Diagnostic Code 5261, limitation of extension of the leg warrants a noncompensable evaluation when extension is limited to 5 degrees; a 10 percent evaluation when limited to 10 degrees; a 20 percent evaluation when limited to 15 degrees; a 30 percent evaluation when limited to 20 degrees; a 40 percent evaluation when limited to 30 degrees; and a 50 percent evaluation when limited to 45 degrees. For VA compensation purposes, the normal range of motion of the knee is 140 degrees of flexion and 0 degrees of extension. 38 C.F.R. § 4.71, Plate II. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause a functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of 'the normal working movements of the body such as 'excursion, strength, speed, coordination, and endurance,' in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Additionally, the Court has stated that flare-ups must be factored into an examiner's assessment of functional loss. Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. However, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. Criteria effective prior to the February 7, 2021 revision Diagnostic Codes 5003 and 5010 pertains to arthritis. Under Diagnostic Code 5003, the knee disability may be rated under provisions for evaluating arthritis. Diagnostic Code 5003 provides that degenerative arthritis that is established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is non-compensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 10 percent rating is assigned where there is x-ray evidence of involvement of two or more major joints, or two or more minor joint groups; and a 20 percent evaluation is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Note (1) provides that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Id. Diagnostic Code 5010 refers to arthritis due to trauma, substantiated by x-ray findings. The code directs that traumatic arthritis be rated as degenerative arthritis (Diagnostic Code 5003). Id. Diagnostic Code 5257 rates on the basis of recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated as 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated as 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated as a maximum 30 percent disabling. The Board observes that the words "slight," "moderate," and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Use of terminology by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Criteria effective from February 7, 2021 Diagnostic Code 5003 was revised to make clear that this code only applies to degenerative arthritis and not to post-traumatic arthritis. The 10 percent rating for non-compensable limitation of motion has now been removed. Diagnostic Code 5010 was revised to refer to post-traumatic arthritis and the instruction to rate as degenerative arthritis under 5003 was removed. Traumatic arthritis is now rated as "limitation of motion, dislocation, or other specified instability under the affected joint." Diagnostic Code 5257 was revised to remove the terms "severe," "moderate," and "slight" for recurrent subluxation or lateral instability. The revision also adds rating for patellar instability. The revision also includes the language below. Recurrent subluxation or instability: Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation warrants a 30 percent rating. 20 percent rating is warranted for one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation. (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. Patellar instability: A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). 1. Entitlement to a rating in excess of 10 percent for a right knee disability prior to January 8, 2020 is denied. The Veteran was provided with a VA examination to evaluate his knee in May 2015. The Veteran stated that he could not kneel and that his knees were moderately painful going up and down stairs. The Veteran was capable of flexion from 10 to 128 degrees and extension from 136 to 12 degrees. No pain was noted on the examination and there was no evidence of localized tenderness or pain upon palpation. The Veteran was capable of repetitive use testing and after three repetitions the Veteran was capable of flexion from five to 137 degrees and extension from 137 to four degrees. The Veteran denied flareups. Muscle strength was 5/5 and there was no evidence of muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion and there was no indication of joint instability. There were no meniscal conditions or surgical procedures noted. There was no arthritis or scars of the right knee. The Veteran underwent another VA examination to evaluate his knees in April 2017. The Veteran complained of intermittent, achy pain in the right knee and reported flareups nightly. He described this pain as lasting approximately four hours, rated as 6/10 in terms of severity. He denied constant right knee pain, but had increased pain with prolonged walking. The Veteran was capable of flexion to 130 degrees and extension to zero degrees. There was no evidence of pain with weight bearing or pain on palpation of the joint. The Veteran was capable of repetitive use testing without additional functional loss. There was also no additional loss in range of motion due to flareups. Muscle strength was 5/5 and there was no evidence of muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. No joint instability, patellar dislocation, shin splints, stress fractures, or fibular impairments were noted. There were no meniscal conditions, history of surgery, or scars observed. No arthritis was documented, and the examiner determined that there was no functional impact on the Veteran's employability. In January 2018 VA treatment records, the Veteran reported that his right knee was worsening but that he did not need an assistive device for ambulation. At the September 2019 hearing, the Veteran stated that he experienced instability and that he used his shopping cart to balance himself while shopping. In October 2019, the Veteran submitted a privately completed disability benefits questionnaire by a DNP (Doctor of Nursing practice). The Veteran reported flareups and that his knee stiffened with prolonged sitting. Range of motion testing indicated flexion to 78 degrees and extension to zero degrees. After repetitive use testing the Veteran was capable of flexion to 94 degrees and extension to zero degrees. Muscle strength was 5/5 and there was no evidence of muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability was normal and there was no evidence of recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or tibial or fibular impairment. There was no meniscus condition, scars, or arthritis. There was objective evidence of crepitus in the right knee. The DNP determined that the functional impact of the knee condition was the decreased ability to stand or ambulate for extended periods. Upon review of the record, the Board finds that currently assigned ratings for the right knee disabilities are proper and therefore higher ratings are not warranted. Prior to October 24, 2017, the Veteran is rated at 10 percent for limitation of extension under DC 5261. After October 24, 2017 the Veteran is rated at 10 percent under DC 5260 for painful motion. Diagnostic Code 5260 addresses limitation of flexion of the knee. Under it, a 30 percent rating is for application where flexion is limited to 15 degrees; a 20 percent rating is for application where flexion is limited to 30 degrees; a 10 percent rating is for application where flexion is limited to 45 degrees; a 0 percent rating is for application where flexion limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 addresses limitation of extension of the knee. Under it, limitation of extension of the knee to 5 degrees warrants a noncompensable evaluation, limitation of extension of the knee to 10 degrees warrants a 10 percent evaluation, limitation of extension to 15 degrees warrants a 20 percent evaluation, and limitation of extension to 20 degrees warrants a 30 percent evaluation. Limitation of extension of the knee to 30 degrees warrants a 40 percent evaluation and limitation of extension of the knee to 45 degrees warrants a 50 percent evaluation, the highest schedular evaluation under this Diagnostic Code. 38 C.F.R. § 4.71a, Diagnostic Code 5261. At worst the Veteran's flexion was noted to be 78 degrees and extension was limited to 12 degrees. Thus, even when considering additional functional loss and impairment, flexion was not limited to 60 degrees and when considering additional functional loss and impairment, extension was not limited to at least 15 degrees. Accordingly, an increased or separate evaluation is not warranted under these diagnostic codes. See 38 C.F.R. § 4.40, 4.45, 4.59; see also, DeLuca, Mitchell, supra. The Board has considered other potentially applicable diagnostic codes. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Here, there is no evidence of right knee ankylosis, tibia or fibula impairment, genu recurvatum. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263 (2018). The evidence also did not show semilunar cartilage dislocation with frequent episodes of locking, pain, and effusion into the joint or symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259 (2018). The Board notes that the Veteran testified about some instability during the September 2019 hearing; however, there is no probative evidence indicating that the Veteran exhibited such instability. The May 2015 and April 2017 VA examiners performed joint stability testing and noted normal results. The privately submitted October 2019 disability benefits questionnaire also noted normal joint stability. All examinations also denied any indication of recurrent subluxation. The Veteran is certainly competent to report what he perceived as instability in the right knee, but he is not competent to determine whether these symptoms rise to a level that would warrant a compensable rating under Diagnostic Code 5257. The clinical findings are more probative because the examiners considered the Veteran's lay reports, reviewed his medical record, observed his movement, and performed stability testing in the right knee. Therefore, a separate rating for recurrent subluxation or instability is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5257. As such, the Board finds that an evaluation in excess of 10 percent is not warranted prior to January 8, 2020. 2. Entitlement to a rating in excess of 40 percent for right knee disability after January 8, 2020 is denied. The Veteran was provided with a VA examination in January 2020. The Veteran reported right knee aching, popping, and flareups every two weeks lasting two to three days. He noted that he was unable to perform activities of daily living during a flareup and that he had to force his knee to bend. The Veteran was capable of flexion to 140 degrees and extension to 30 degrees. There was objective evidence of pain on palpation and there was evidence of pain with weightbearing. Range of motion with weightbearing was flexion to 140 degrees and extension to 40 degrees. The Veteran was capable of repetitive use testing with no additional loss in range of motion. Pain, weakness, fatigability, and incoordination significantly limited functional ability with repeated use over time. The Veteran was capable of 140 degrees of flexion and 30 degrees of flexion. The same range of motion resulted with flareups. Muscle strength was 5/5 for flexion and 2/5 for extension. The Veteran did not have muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. There was no evidence of recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or tibial or fibular impairment. There were no meniscus conditions, scars, or arthritis. The examiner determined that the Veteran's knee condition impacted his ability to work as he experienced pain with walking, using stairs, and lifting. The Veteran was provided with a final VA examination in May 2021. The Veteran reported flareups and noted that the weather caused achy pain and slowed his ambulation. The examiner noted that the Veteran's knee pain increased after repetitive use. The examiner observed that the Veteran experienced recurrent effusion due to knee strain at the end of the day. The Veteran was capable of flexion to 110 degrees and extension to zero degrees. There was evidence of crepitus. After repetitive use testing the Veteran's flexion was limited to 105 degrees. Additional factors contributing to disability such as interference with standing, interference with sitting, disturbance of locomotion, swelling, less movement than normal, and weakened movement were noted. The Veteran did not have muscle atrophy or ankylosis. There was no history of recurrent subluxation, persistent instability, or recurrent patellar instability. No joint instability, patellar dislocation, shin splints, stress fractures, or fibular impairments were noted. The Veteran did not have a meniscus condition or history of surgery. The examiner determined that the Veteran's right knee made it difficult for him to walk stairs, run, walk, and squat. The Veteran is evaluated at 40 percent under DC 5261 for limitation of extension after January 8, 2020. At worst the Veteran's flexion was noted to be 105 degrees and extension was limited to 40 degrees. Thus, even when considering additional functional loss and impairment, flexion was not limited to 60 degrees and when considering additional functional loss and impairment, extension was not limited to at least 45 degrees. Accordingly, an increased or separate evaluation is not warranted under these diagnostic codes. See 38 C.F.R. § 4.40, 4.45, 4.59; see also Deluca, Mitchell, supra. The Board has considered other potentially applicable diagnostic codes. Here, there is no evidence of right knee ankylosis, tibia or fibula impairment, genu recurvatum or recurrent subluxation or instability. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263, 5257 (2018). The examiner in the May 2021 VA examination did indicate that there was evidence of recurrent effusion, however there is no indication in the January 2020 or May 2021 VA examinations that the Veteran experienced dislocation of the semilunar cartilage or any kind of meniscal condition. The evidence thus does not show semilunar cartilage dislocation with frequent episodes of locking, pain, and effusion into the joint or symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a , Diagnostic Codes 5258, 5259. In sum, the preponderance of the evidence is against an increased evaluation under DC 5261, or an additional separate rating under any other Diagnostic Code either under the old or new regulations. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; as the preponderance of the evidence is against assignment of any other higher ratings, it is not applicable. 38 U.S.C. § 5107. 3. Entitlement to service connection for a lumbar spine disability is denied. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection for certain chronic diseases, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran alleges that his lumbar spine condition is secondary to his service-connected right knee condition. In the September 2019 hearing transcript, it was reported that the Veteran's spine condition manifested after his right knee condition approximately 10 years following service. First, the Board finds that there is a current disability. According to the January 2020 VA examination, the Veteran is diagnosed with degenerative arthritis of the spine. Second, the Board finds that there is a properly service-connected condition. The Veteran is service connected for the right knee condition that he believes caused or aggravated his back condition. Third, the Board finds that the probative evidence of record does not support a finding that the lumbar spine condition is caused or aggravated by his service-connected right knee condition. The Veteran was provided with a VA examination in April 2016. The examiner denied nexus, finding that the Veteran's degenerative disc disease was due to the normal aging process and the physical work he had done most of his life. The examiner also denied aggravation of the Veteran's back condition by his right knee condition as there was no evidence of aggravation. This opinion is afforded less probative weight as it is conclusory and lacks any medical explanation or support for the opinion. In September 2019, the Veteran submitted a private opinion from an Advanced Practice Registered Nurse (APRN). The APRN opined that the Veteran's back condition was at least as likely as not caused by the deleterious cascading effect of the antalgic gait that resulted from the Veteran's right knee condition. Again, the opinion is provided less probative weight due to the conclusory nature of the statement and lack of rationale. A VA examiner provided an opinion in February 2020. The examiner denied nexus and as rationale only noted that the Veteran stated that the onset of back problems was 10 years ago, 38 years following service. The examiner then included a passage from a medical website, which stated that the causes of low back injuries were difficult to identify. The Board finds this opinion to be inadequate as it is conclusory and without proper rationale. Another VA opinion was provided in June 2021. The examiner again found that the Veteran's lumbar spine condition was less likely than not related to service. The examiner noted that there was no evidence of a back injury in the STRs. The examiner stated that the Veteran did not report problems with his back until 2010. The examiner then stated that degenerative joint disease was a naturally occurring condition that developed with age and that 2010 to 2016 when the Veteran first began complaining of back issues was an age-appropriate time to be experiencing this condition. The examiner then explained that the condition did not spread from one joint to another including through gait accomodation. The examiner stated that the September 2019 private opinion was broad and general without plausible rationale and was inconsistent with accepted medical knowledge. The examiner noted that more than 50 percent of men over 50 exhibited the condition with the prevalence of the condition rising significantly with each decade. The examiner then stated that there was no evidence of aggravation as the natural course of the condition was progression often requiring medical and surgical intervention. The examiner noted that gait accomodation did not aggravate degenerative spine disease. He stated that there were rare exceptions, but noted that a discrepancy of more than five percent in the length of the leg or a chronic exaggerated Trendelenburg gait was necessary to cause any sequela in the lumbar spine and the Veteran did not exhibit such symptoms. The examiner concluded that the Veteran's claims were contradicted by the available medical evidence and his own statements concerning the onset of his spine condition. The Board finds this opinion to be highly probative evidence as it is provided upon review of the relevant facts (to include lay statements of symptomatology and onset that the Board found probative) and is supported by thorough medical explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in determining probative value of a medical opinion is whether the examiner was informed of the relevant facts); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). The Veteran is certainly competent to described his symptoms, but he is not competent to provide a nexus to service or an opinion as to secondary service connection. He has not been shown to have the medical expertise to provide such opinions. To the extent that he may be claiming continuity of symptomatology, his statements are contradicted by the more probative evidence of record. He was not diagnosed as having arthritis of the spine within one year of active duty, and specifically reported the onset as being 10 years following service. Therefore, presumptive service connection is not warranted. As the only probative opinion of record indicates that there is no nexus between the Veteran's current back disability and service, nor is it secondary to the service-connected right knee disability, service connected must be denied. (Continued on the next page) In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board AK 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.