Citation Nr: 21005275 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 08-25 807 DATE: February 1, 2021 ORDER Entitlement to a disability rating in excess of 10 percent for service-connected seborrheic dermatitis scalp (herein referred to as a “dermatitis condition”), is granted. Entitlement to service connection for a right kidney removal is denied. Entitlement to service connection for a right knee disability to include as secondary to service-connected left knee and left ankle disabilities is denied. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his dermatitis condition manifested as at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected. 2. The Veteran's right kidney removal was the result of a congenital defect; the Veteran did not experience a superimposed disease or injury during active service that resulted in an additional disability or aggravation of this disorder. 3. The preponderance of the evidence is against finding the Veteran’s right knee disability was related to active duty service or to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for a service-connected dermatitis condition are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Codes 7806. 2. The criteria for entitlement to service connection for the removal of the right kidney are not met. 38 U.S.C. § 1131, 5107; 38 C.F.R. §§ 3.303(c), 4.9. 3. The criteria for entitlement to service connection for a right knee disability to include as secondary to a service-connected disability, are not met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1975 to October 1979. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from January 2007, August 2010, and February 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The procedural history of this case is as follows: in June 2014, the Board issued a rating decision denying entitlement to service connection for a right kidney removal. The Veteran subsequently appealed the June 2014 Board decision to the U.S. Court of Appeals for Veteran’s Claims (CAVC) and in January 2015 CAVC issued a Joint Motion for Partial Remand (JMPR) after finding the Board did not provide adequate basis and reasoning in denying the claims listed in the June 2014 Board decision. At this point, his claim for a right kidney removal returned to the Board. In September 2015, the Board remanded the Veteran’s increased rating claim, kidney removal claim, and right knee disability claim. Subsequent development followed and in January 2019, the Board once again remanded the Veteran’s claims for further development. The Board finds substantial compliance with the January 2019 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). INCREASED RATING Turning to the merits of the Veteran’s claim, disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that during the appeal period, changes were made to 38 C.F.R. § 4.118, Diagnostic Code 7806. Effective August 13, 2018, VA amended its regulations governing skin disabilities. VA's intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. 83 Fed. Reg. 32592 (July 13, 2018). Under both the pre-August 2018 rating criteria and the post-August 2018 rating criteria for Diagnostic Code 7806, a 0 percent rating is assigned where no more than topical therapy is required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the exposed area affected or characteristic lesions involving less than 5 percent of the entire body affected. 38 C.F.R. § 4.118. A 10 percent rating is assigned where there is involvement of at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. Id. A 30 percent rating requires involvement of 20 to 40 percent of the entire body or of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Id. A maximum rating of 60 percent requires involvement of more than 40 percent of the entire body, or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Id. The Board notes the holding in Johnson v. McDonald, 27 Vet. App. 497 (2016), which held that topical use of either corticosteroids or other immunosuppressive drugs is considered "systemic" therapy for purposes of rating under DC 7806. Thereafter, in Johnson v. Shulkin, the United States Court of Appeals for the Federal Circuit (Federal Circuit) reversed this decision and determined that "constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs" under Diagnostic Code 7806 is generally not inclusive of topical corticosteroids. 862 F.3d 1351, 1352 (Fed. Cir. 2017). The Federal Circuit found that "systemic therapy" meant "treatment pertaining to or affecting the body as a whole," while topical therapy meant "treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied." Id. at 1355 (citation omitted). The Federal Circuit also held that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole. Thus, in a given case, the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances. Following the Federal Circuit's decision, the United States Court of Appeals for Veterans Claims (Court) again addressed "systemic therapy" in the context of topical treatment in Burton v. Wilkie, 30 Vet. App. 286 (2018). The Burton Court stated that, when considering topical therapy as systemic therapy, the Federal Circuit's Johnson decision was not limited to situations involving large-scale application of topical treatment. Id. at 291. Rather, the Court held that there are at least 2 other potential ways of showing that a topical treatment is systemic: (1) the method by which the topical treatment works, and (2) its side effects. Id. For claims filed prior to August 13, 2018, in considering whether a treatment is systemic, the Board must also consider whether the treatment affects the body as a whole and whether the given treatment is like or similar to a corticosteroid or other immunosuppressive drug. See Burton v. Wilkie, 30 Vet. App. 286 (2018). The post-August 2018 rating criteria clarify that systemic therapy includes, but is not limited to corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, and other immunosuppressive drugs. 38 C.F.R. § 4.118. Increased rating for a dermatitis condition The Veteran seeks entitlement to a compensable disability rating for his dermatitis condition. Turning to the evidence of record, in March 2010, VA treatment records indicate he received treatment for his dermatitis condition and was prescribed “Selenium sulfate lotion” and “Fluocinonide solution.” In April 2010, the Veteran underwent a VA skin conditions examination report which included a review of the claims file, a recitation of complaints and medical history, and physical examination results. The report noted, in addition to the above-mentioned prescriptions, he was also prescribed Ketoconazole shampoo “applied daily” for a “fungal infection.” Under the section entitled rash, the examiner wrote the following: “The rash has been continuous since it began in 1976. Localized on the scalp only and has never resolved. He has been treated with topical steroids… There have been no systemic steroids used.” Under the section entitled skin, the examiner wrote: All toenails are involved with the fungus, which is approximately 0.5% of the total body surface area and 0% of the exposed body surface area… Evaluation of the scalp does not reveal any active rash at this time. There are no rashes noted on other areas of the body. In July 2010, VA treatment records indicate he received treatment for his dermatitis condition and was prescribed Doxycyline and was instructed to “continue other medications, like the Synalar lotion and Selsun shampoo.” In August 2010, VA treatment records indicate he was again prescribed Ketoconazole. In May 2011, September 2011, and July 2012 VA treatment records indicate he was prescribed Clobetasol, a corticosteroid. In September 2015, the Veteran’s claim was remanded for further development. From January 2017 to August 2017, VA treatment records indicate he was again prescribed Ketoconazole and Clobetasol. In August 2018 VA treatment records indicate he was again prescribed Ketoconazole. In September 2018, a VA medical opinion was entered into the claims file. The report noted he had active prescriptions for Ketoconazole and Selenium Sulfide shampoo. The Veteran subjectively reported: The rash on his scalp is much better… that he uses shampoo, 3 times per week… that the real reason of his claim is due to his foot fungus. He reports that he uses cream, that his caretaker applies to his 3 times per week. He also reports that at times the fungus may appear in his hands. The examiner determined the Veteran did not have a current skin condition; specifically writing, “Normal scalp examination. There is no evidence of dermatophytosis. Veteran does have atrophic nails possibly due to onychomycosis.” As to medication, the report determined he used no more than topical medication for a duration of six weeks or more, but not constant. Also, the report determined he did not have any characteristic lesions during the examination, and he did not have any scarring of the head, face, or neck. In January 2019, the Veteran’s claim was once again remanded for further development. In September 2019, a VA medical addendum opinion was entered into the claims file. The addendum opinion noted the Veteran’s medical history and prescription history as it pertained to his dermatitis condition. The report determined that none of the Veteran’s prescriptions qualify as systemic therapy and they are all considered topical treatments that are used to treat a limited area of the body. In August 2020, a VA Form 21-6789 Deferred Rating was entered into the claims file requiring an addendum opinion as to the nature of the Veteran’s use of the corticosteroid Clobetasol. In August 2020, the requested VA medical addendum opinion was added to the claims file. The examiner noted the following about Clobetasol, “It is applied to the skin as a cream, ointment, or shampoo. Use should be short term and only if other weaker corticosteroids are not effective.” Ultimately the examiner opined: “Therefore, this is a topical medication. There is no objective evidence to support that the medication was administered on a large enough scale that affected the entire body. The medication is not a systemic therapy.” After review of the claims file and in conjunction with the applicable laws and regulations, the Board finds that resolving reasonable doubt in favor of the Veteran, the evidence of record is in relative equipoise as to whether his dermatitis condition manifested at a 10 percent disability rating. Under both the pre-August 2018 rating criteria and the post-August 2018 rating criteria for Diagnostic Code 7806, a 10 percent rating is assigned where there is involvement of at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. 38 C.F.R. § 4.118. Here, the August 2018 VA examiner recognized the Veteran’s dermatitis condition was affecting the Veteran’s scalp. However, the examiner did not provide an estimation of the total body affected by the Veteran’s dermatitis condition. Moreover, the examiner did not consider the Veteran’s prolonged and continued use of the corticosteroid Clobetasol from May 2011 to July 2012 and from January 2017 to August 2017. Indeed, the September 2019 and August 2020 addendum opinions also did not include estimations of the body affected by the dermatitis condition. As such, the VA examination and addendum opinions provide little probative value. However, the Board finds that to remand for a VA examination is not necessary and would only cause undue delay in adjudicating the claim. Moreover, the Board finds that since the evidence of record indicates his condition has continuously affected his scalp, that represents a fairly significant portion of the affected area. As such, and granting all reasonable doubt to the Veteran, the Board finds the Veteran’s dermatitis affected scalp represents at least 5 percent, but less than 20 percent, of the exposed areas affected. 38 C.F.R. § 4.118. In conclusion, resolving reasonable doubt in the Veteran’s favor and considering the extreme length of time since he filed his claim and the date of this decision, the Board finds the evidence of record is in relative equipoise as to whether his dermatitis condition manifests at a 10 percent disability rating, but no higher. To the extent that a disability rating in excess of 10 percent is sought, the preponderance of the evidence is against the claim. Hence the benefit of the doubt rule does not apply. Gilbert, 1 Vet. App. 49; 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. As such, affording all benefit of the doubt to the Veteran, the Board finds that the Veteran’s dermatitis condition warrants a 10 percent disability rating, but no higher. SERVICE CONNECTION The Veteran seeks entitlement to service connection for a right kidney removal and entitlement to service connection for a right knee disability to include as secondary to his service-connected left knee and ankle disabilities. These appeals are before the Board of Veterans’ Appeals (Board) from multiple rating decisions from Department of Veterans Affairs (VA) Regional Offices (RO). The procedural history is as follows: In June 2014, the Board issued a rating decision denying entitlement to service connection for a right kidney removal. In July 2014, the Veteran filed a claim of entitlement for a right knee disability. The Veteran subsequently appealed the June 2014 Board decision to the U.S. Court of Appeals for Veteran’s Claims (CAVC) and in January 2015 CAVC issued a Joint Motion for Partial Remand (JMPR) after finding the Board did not provide adequate basis and reasoning in denying the claims listed in the June 2014 Board decision. At this point, his claim for a right kidney removal returned to the Board. In a February 2015 rating decision, the AOJ denied the Veteran’s claim of entitlement for a right knee disability. In September 2015, the Board remanded the Veteran’s kidney removal claim in compliance with the January 2015 JMPR. Subsequent development of both claims followed culminating in a January 2019 Board decision that remanded both claims for further development. The Board finds substantial compliance with the January 2019 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). As to the legal criteria, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In rendering a decision on appeal, the Board must analyze the credibility and probative value of all medical and lay evidence of record, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. 38 U.S.C. § 1154(a); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board must resolve reasonable doubt in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Service connection for right kidney removal In addition to the regulations cited above, congenital or developmental defects automatically rebut the presumption of soundness and are considered to have preexisted service. 38 C.F.R. §§ 3.303(c), 4.9. As such, service connection is generally precluded for such defects because they are not “diseases or injuries within the meaning of applicable legislation.” 38 C.F.R. §§ 3.303 (c), 4.9, 4.127; see also Terry v. Principi, 340 F.3d 1378, 1383-84 (Fed. Cir. 2003). Nonetheless, service connection may be awarded for a congenital defect if there is evidence of additional disability due to aggravation during service of the congenital defect by superimposed disease or injury. See VAOPGCPREC 82-90; Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993); VAOPGCPREC 67-90; and VAOPGCPREC 11-99. Turning to the evidence of record, the Veteran’s service treatment records (STRs) indicate in September 1976 he was treated for a possible urinary tract infection. Also, in September 1976 and May 1977, he was treated for back and side pain with painful urination. In February 1977 and October 1979, he was treated for prostatitis. His August 1979 separation examination does not list any issues related to a kidney disability. In December 2005, VA treatment records indicate he underwent surgery to place stents in his kidney to treat blockage and pain. In April 2006, VA treatment records indicate he underwent surgery to remove his right kidney. In a May 2006 letter to the Board, the Veteran’s private physician opined the lack of in-service treatment and diagnosis of his right kidney condition, utero-pelvic junction obstruction (UPJO), lead to the removal. The physician opined that when he received treatment for prostatitis “this may have been symptoms of UPJO. If it was caught early, the kidney could have been saved.” In November 2006, he underwent a VA kidney examination report which included a review of the claims file, a recitation of complaints and medical history, and physical examination results. The report ultimately determined the Veteran’s right kidney removal was not caused by or the result of active duty service. In a September 2012 informal hearing presentation (IHP), the Veteran’s representative alleged his underlying condition was misdiagnosed while in active duty service and the misdiagnosis lead to his kidney removal. In October 2012, the Board remanded the Veteran’s claim for further development after determining the November 2006 VA examination was inadequate. In November 2012, the Veteran underwent a VA kidney examination report which included a review of the claims file, a recitation of complaints and medical history, and physical examination results. The examiner noted that UPJO generally occurs as a baby and is considered a congenital condition that is present at birth. The examiner acknowledged the May 2006 private physician letter; however, the examiner referred to the physicians own statements that the opinion was speculative in nature. The examiner determined the Veteran was born with his kidney condition and that it was not caused by or related to active duty service or aggravated beyond its natural progression by a service-connected disability or by any injury incurred during his active duty service. In June 2014, the Board denied the Veteran’s claim. However, the Veteran appealed to CAVC and they issued a January 2015 JMPR which remanded the Veteran’s claim back to the Board to determine if the Veteran’s kidney disability was “subject to additional, superimposed disease or injury during service.” Accordingly, in September 2015 the Board remanded the Veteran’s claim. In September 2018, a BVA medical opinion was entered into the claims file which included a review of the claims file and a recitation of his medical history and complaints. The opinion determined the Veteran’s condition clearly and unmistakably existed prior to active duty service and that there was no objective evidence to indicate the condition was aggravated by military service, to include prostatitis, back pain, and urinary tract infections. Specifically writing, “such a nexus cannot be supported by any known pathophysiological model nor by any peer reviewed medical literature.” The report also determined his UPJO to be a congenital defect and that there was no objective medical evidence to support the condition was aggravated by military service, to include prostatitis, back pain, and urinary tract infections, as “such a nexus cannot be supported by any known pathophysiological model nor by any peer reviewed medical literature.” Lastly, the opinion determined his kidney disease clearly and unmistakably existed prior to his active duty service and clearly and unmistakably underwent no permanent increase in severity as a result of his active duty service. In January 2019, the Board once again remanded the Veteran’s claim after determining the September 2018 addendum opinion did not specifically address whether the Veteran’s congenital kidney disorder was subject to an additional or superimposed disease or injury during service. In September 2019, a VA addendum opinion was entered into the claims file which included a review of the claims file and a recitation of his medical history and complaints. The addendum opinion states, “There is no objective evidence to support any superimposed additional disability during service time. Veteran’s current renal insufficiency as likely due to aging combined with nephrectomy.” The opinion cited to medical literature on the nature and general causes of UPJO. After a review of the claims file in conjunction with the applicable laws and regulations, the Board finds the preponderance of the evidence is against finding the Veteran’s right kidney removal is in any way related to active duty service. Furthermore, the Board finds the preponderance of the evidence is against finding his congenital kidney disease was subject to an additional, superimposed disease or injury during service. As to direct service connection, the Board recognizes the Veteran had his kidney removed. Thus, the first element of service connection is established. See Shedden, 381 F.3d at 1167. However, the evidence of record does not contain the second and third required elements; specifically, an in-service event and a medical nexus connecting his disability to his active duty service. While the Board acknowledges the May 2006 private physician letter, the Board finds her opinion is speculative in nature by stating his in-service issues “may” have been evidence of his UPJO congenital defect. Furthermore, the November 2012 and September 2018 VA examiners and the September 2019 addendum opinion determined the Veteran’s right kidney removal was not caused by or related to any of his in-service prostatitis, urinary tract infections, back pain, or any other in-service injury. Moreover, the evidence of record is devoid of any competent or credible medical evidence or opinions to counter the November 2012 and September 2018 VA examinations and the September 2019 addendum opinion. As to the claim that his congenital kidney disease was subject to an additional superimposed disease or injury during service, the preponderance of the evidence is against the claim. See generally VAOPGCPREC 82-90; Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993); VAOPGCPREC 67-90; and VAOPGCPREC 11-99. The Board once again acknowledges the May 2006 private physician letter; however, the Board reiterates that her opinion is speculative in nature and does not render an ultimate opinion if his kidney disease was subject to an additional superimposed disease or injury during service. Moreover, the September 2019 addendum opinion determined there was “no objective medical evidence” to indicate his congenital kidney disease was subject to an additional superimposed disease or injury during service. Furthermore, the evidence of record is devoid of any competent or credible medical evidence or opinion to counter the findings of the September 2019 addendum opinion. Indeed, the only evidence of a connection in any way between the Veteran’s right kidney removal and his active duty service are the Veteran’s own lay statements. Lay evidence may be competent to establish medical etiology or nexus (Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009)), but VA can give lay evidence whatever weight to which it concludes the evidence is entitled. Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010). In this case, although the Veteran may believe his right kidney removal is related to active duty service, was aggravated by active duty service, or subject to an additional superimposed disease or injury in-service, he is not competent to make such determinations, which are medical in nature. See Jandreau, 492 F.3d at 1372. Such opinions require specialized training and knowledge and are matters which are not capable of lay observation. As such, the Board finds the Veteran’s contentions are of little probative value. In conclusion, the preponderance of the evidence is against finding the Veteran’s right kidney removal is in any way related to active duty service or subject to an additional superimposed disease or injury during active duty service. Hence, the benefit of the doubt rule does not apply. Gilbert, 1 Vet. App. 49; 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Accordingly, the Veteran's claim of entitlement to service connection for a right kidney removal is denied. Service connection for a right knee disability In addition to the previously cited regulations, service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. For certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Turning to the evidence of record, the STRs do not indicate that at any point the Veteran voiced complaints related to or received treatment related to right knee pain during active duty service. The evidence of record also indicates the Veteran had subsequent Reserve and/or National Guard service. In May 1982 the Veteran was awarded service connection for left knee and ankle disabilities. In December 1981 and at some point, in 1982, VA treatment records indicate he underwent surgery for a right knee cartilage injury. In October 1989, VA treatment records indicate he received treatment for a right knee injury after, “He was trying to lift a 300-pound machine off of a pickup truck when he slipped. The machine came down on his right knee.” The Veteran reported that in 1996, he underwent surgery for a right knee injury and that his 1980’s knee injuries occurred while as “a civilian contractor.” See May 2006 VA Treatment Record. Between April 2001 and April 2007, VA treatment records indicate he received treatment for right knee pain on eight occasions. VA treatment records also indicate he has received treatment for knee arthralgia since December 2007. In April 2008 VA treatment records indicate he received treatment for right knee pain and was given a knee brace. In December 2011 VA treatment records indicate he received treatment related to right knee pain and was diagnosed with osteoarthritis. In January 2012 he underwent treatment for right knee pain. In April and September 2012, VA treatment records indicate he received a right knee steroid injection. In June 2014, VA treatment records indicate he received treatment for bilateral knee pain and he subjectively reported the following, “his right knee symptoms are generally always worse since he has had a stroke affecting his left lower extremity.” In a July 2014 statement to the Board, the Veteran alleged his right knee disability is the result of his service-connected left knee and ankle disabilities. In February 2015, the Veteran underwent a VA knee conditions examination report which included a review of the claims file, a recitation of complaints and medical history, and physical examination results. The examiner ultimately opined that it was less likely than not his right knee disability was proximately due to or the result of his service-connected left knee and ankle disabilities. Specifically, the examiner stated: “These conditions are separate mechanical injuries and involve different anatomical locations. The one is not the cause or related to the other.” The examiner also opined the right knee condition was less likely than not aggravated beyond its natural progression by his service-connected left knee and ankle disabilities. Specifically, the examiner opined, “There is no current objective evidence to support the progression or deterioration of meniscal tear and left ankle disability. Recent bilateral knee x-ray show osteoarthritis, consistent with age.” In May 2017 VA treatment records indicate he received treatment for right knee pain. In August 2017, VA treatment records indicate he received a right knee steroid injection. In January 2019, the Board remanded the Veteran’s claim for further development after determining the February 2015 VA examiner did not address whether the Veteran’s reported gait disturbance caused or aggravated his right knee disorder. In September 2019, a VA addendum opinion was entered into the claims file. The opinion cited to multiple sources of medical literature in determining the Veteran’s right knee disability was not related to his service-connected left knee and ankle disabilities. The cited medical literature indicates people tend to allege knee and leg injuries cause a person to “favor” the other leg and/or limp and that it unduly stresses the normal leg causing damage. However, the medical literature states in pertinent part: In particular, few references have been found to the effect of the limp on the other leg. The evidence available indicates that an injury in one extremity rarely causes a major problem in the opposite or uninjured extremity. On August 3, 2020, a Deferred Rating was entered into the claims file after the VA determined the September 2019 addendum opinion did not properly address aggravation and did not provide an estimation of the baseline symptomatology if aggravation was found. On August 11, 2020, a VA addendum opinion was entered into the claims file. The addendum opinion stated, “Correia cannot be addressed,” since the September 2019 addendum opinion was only a review of the claims file. On August 19, 2020, a Deferred Rating was entered into the claims file after the VA determined the August 2020 addendum opinion had still not met the standards put forth in the Boards January 2019 remand. On August 24, 2020, another VA addendum opinion was entered into the claims file. However, this opinion was identical to the September 2019 addendum opinion. Subsequently, on October 8, 2020, a third Deferred Rating was entered into the claims file to acquire a VA medical opinion that met the standards required by the January 2019 Board remand. Specifically, any medical opinion must address the Veteran’s claim of a “pronounced awkward gait.” On October 15, 2020, a VA addendum opinion was entered into the claims file. The opinion stated that there is “no objective evidence to support that condition was aggravated beyond its natural progression” by his service-connected left knee or ankle disabilities. Additionally, the opinion included medical literature previously cited in the September 2019 and multiple August 2020 opinions that injuries to one extremity “rarely” cause injury to another and thus any “limp” or “pronounced awkward gait” due to his service-connected left knee and ankle disabilities did not cause, affect, or aggravate his right knee disability. After a review of the claims file in conjunction with the applicable laws and regulations, the Board finds the preponderance of the evidence is against finding the Veteran’s right knee disability was related to active duty service or to a service-connected disability. As an initial matter, although the Veteran’s right knee disability is characterized as a form of arthritis, his right knee disability was not shown to have manifested by any symptomatology during or within one year of separation from active service, the presumptive service connection provisions for chronic diseases under 38 C.F.R. §§ 3.303(b), 3.307(a)(3) and 3.309(a) are not applicable. As to direct service connection, the Board recognizes the Veteran is diagnosed with multiple right knee disabilities. Thus, the first element of service connection is established. See Shedden, 381 F.3d at 1167. However, the evidence of record does not contain the second and third required elements; specifically, an in-service event and a medical nexus connecting his disability to his active duty service. Here, the STRs do not indicate that at any point the Veteran received treatment for, or voiced complaints related to a right knee disability. While the Board acknowledges his multiple right knee injuries in the 1980’s and in 1996, the evidence of record and the Veteran’s own lay statements indicate these injuries occurred while “as a civilian contractor.” Moreover, the evidence of record contains no indications and the Veteran does not claim these injuries were incurred during the Veteran’s subsequent Reserve and/or National Guard service. Furthermore, other than the previously mentioned knee injuries, the evidence of record is devoid of any complaints of or treatment related to his current right knee disability until 2001; 22 years after active duty service. Additionally, the evidence of record is devoid of any competent or credible medical evidence indicating that his current right knee disability is related to his active duty service. As to secondary service connection, the Board acknowledges the Veteran is currently service connected for left knee and ankle disabilities. As such, he fulfills the first requirement for service connection on a secondary basis. See 38 C.F.R. § 3.310. However, the evidence of record does not support the finding that his right knee disability was aggravated by, proximately due to, or the result of a service-connected disability. Here, as requested in the January 2019 Board remand, the October 15, 2020 opinion explicitly refuted the Veteran’s argument that his “pronounced awkward gait” due to his service-connected left knee and ankle disabilities caused, affected, or aggravated his right knee disability as this argument is not supported by pertinent medical literature. The Board quotes the medical literature in pertinent part, “The evidence available indicates that an injury in one extremity rarely causes a major problem in the opposite or uninjured extremity.” Furthermore, the October 2020 addendum opinion determined there was “no objective evidence to support that condition was aggravated beyond its natural progression” by any of his service-connected disabilities.. As such, considering the evidence of record as a whole, all of the competent and credible medical evidence of record indicates the Veteran’s right knee disability is in no way related to his service-connected left lower extremity disabilities. Indeed, the only evidence of a medical nexus between his current disability and his active duty service and of causation or aggravation by a service-connected disability are the Veteran's own lay statements. Lay evidence may be competent to establish medical etiology or nexus (Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009)), but VA can give lay evidence whatever weight to which it concludes the evidence is entitled. Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010). In this case, although the Veteran may believe his right knee disability is related to active duty service and may be caused by or aggravated by his service-connected disabilities, he is not competent to make such determinations, which are medical in nature. See Jandreau, 492 F.3d at 1372. Such opinions require specialized training and knowledge and are matters which are not capable of lay observation. As such, the Board finds the Veteran's contentions are of little probative value. In conclusion, the preponderance of the evidence is against finding the Veteran’s right knee disability is related to active duty service or to a service-connected disability. Hence the benefit of the doubt rule does not apply. Gilbert, 1 Vet. App. 49; 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Accordingly, the Veteran's claim of service connection for a right knee disability to include as secondary to a service-connected disability is denied. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Law Clerk, Tyler R. Masters 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.