Citation Nr: 21009498 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 18-07 526 DATE: February 22, 2021 ORDER Entitlement to service connection for a back disability (lumbar strain) is granted. Entitlement to service connection for a right knee disability (degenerative joint disease) is granted. REMANDED Entitlement to service connection for a left knee disability is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his lumbar strain is at least as likely as not related to his service. 2. Resolving reasonable doubt in the Veteran’s favor, his right knee degenerative joint disease is at least as likely as not related to his service. CONCLUSIONS OF LAW 1. The criteria for service connection for lumbar strain are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for degenerative joint disease are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1982 to January 1985 and February 1986 to April 1991. These matters come to the Board of Veterans’ Appeals (Board) from a decision of the Agency of Original Jurisdiction (AOJ). In March 2016, the AOJ issued a rating decision that denied the Veteran’s claims for service connection for lumbar strain, degenerative joint disease of the right knee, and residuals left knee post arthroscopy. The Veteran timely disagreed in an April 2016 Notice of Disagreement (NOD) and perfected his appeal in a January 2018 VA Form 9. In February 2019, the Board remanded the claims so the AOJ can provide a new VA disability examination that considered newly submitted evidence. In October, the VA conducted new VA disability examinations and readjudicated the claims; the AOJ continued its denial of service connections claims for his back disability as well as left and right knee disabilities. In October 2020, the Veteran’s case was received at the Board. 1. Entitlement to service connection for lumbar strain. The Veteran contends his lumbar strain (back disability) is related to his service. The question for the Board is whether there is sufficient evidence to find that the Veteran’s back disability is related to his service. For the reasons discussed below, the Board concludes that the evidence supports a grant of service connection. Entitlement to service connection requires a Veteran to provide evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (2007). Lay evidence, such as a claimant’s statement, can be competent and sufficient to establish a diagnosis of a condition when (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing the symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). A lay person’s statement is competent if he or she has personal knowledge which is gained through the senses, to include what is heard, felt, seen, smelled, and tasted. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In order to prevail on a claim for benefits, the Veteran need only demonstrate there is an approximate balance of positive and negative evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). This is because the Veteran is entitled to the “benefit of the doubt” when the evidence is approximately balanced. Id. at 53. Beginning with the Veteran’s service, his entrance exam for his first period of service (July 1982 to January 1985) does not note any knee or back conditions. See December 28, 1991, Report of Medical Exam. And the questionnaire the Veteran completed as part of that exam does not report any injuries. See December 28, 1991, Report of Medical History. The first in-service complaint of right knee pain was on July 30, 1982, during basic training; he reported he injured that knee during mandatory physical training, and it had been hurting for five days. He complained again on June 23, 1984; he attributed the pain to a basketball injury the day before. Then, during a follow-up visit, on June 25, the medical examiner noted the Veteran had a right strain medial meniscus, possibly torn. Later, on July 6, he reported to sick-call complaining of right and left knee pains; the doctor noted “knee injury resolving.” The following month, on August 15, 1984, he visited sick-call again; this time he reported observing back pains that had lasted about 24 hours and was not sure what caused it. The doctor noted it was a possible muscle pull. On the same day, the Veteran complained of right knee pains; he reported he injured his knee playing basketball the year before. The Veteran also claimed his knee hurt following mandatory physical fitness training. The doctor noted recurring tear of medial meniscus. During his January 29, 1986, entrance exam for his second period of service (February 1986 to April 1991) he reported observing swollen or painful joints; the doctor who evaluated his comments noted the Veteran suffered a right knee sprain that resolved. The doctor also noted the Veteran suffered a back strain about a year ago; it resolved as well. See January 29, 1986, Report of Medical History at 2. Later, on March 27, 1990, the Veteran went to the medical clinic again; he complained of right knee and back pains; the doctor noted lower back strain. Then, on March 29, he returned to sick call due to back pains; he reported an incident five days before, when he fell on his butt. On April 19, he visited sick-call because his back pains prevented him from sleeping. He went back to sick-call in May and June 1990, when he was assessed as having chronic low back pain. He went back to sick-call in October with complaints of back pains; he was asked about any motor vehicle accidents and denied involvement in any. Later, on November 16, 1990, he reported to sick call again; he reported right knee pains that persisted over the last 48 hours. He also reported he hit his knee on the bed of a truck; he was assessed with chronic knee pain. At his separation exam, on March 28, 1991, the doctor did not note any injuries. See March 28, 1991, Report of Medical Exam. Private medical records incorporated into the Veteran’s the file show, that in August 1999, he was seen and treated for back pains by C.W., MD; he noted the Veteran has a “long history of back pains” and “most likely” has degenerative disc disease at the lumbar spine. See August 11, 1999, Record by C.H.W., MD. But the following month, he informed the Veteran that MRI images showed no evidence of degenerative disc disease. See September 8, 1999, Record by C.H.W., MD. In March 2016, the Veteran underwent a VA disability examination for his back disability. The Veteran reported he began experiencing low back pain during service. He attributed it to his military training, to include ruck marching and repetitive lifting. See March 2016 VA disability benefits questionnaire (DBQ) at 2. As for his current symptoms, he observes moderate to severe low back pain that radiates down into both legs. He added that he experiences low back pain at a frequency of two to three times a week. Id. The examiner noted the diagnoses of lumbar strain. He added that a more precise diagnosis could not be provided at the moment. Id. at 1. Then the examiner concluded the Veteran’s back disability is not related to his service. The examiner acknowledged the Veteran had been treated for back pains during service but emphasized there is an absence of objective evidence of treatment for that disability through 2014. And the VA medical center (VAMC) records after 2014 do not mention a low back condition. Id. at 8. The Board notes the Veteran’s claim was remanded because the Veteran submitted medical records after his VA disability examination that showed treatment for a back condition for the period between 1991 and 2014. In October 2019, the Veteran underwent another VA disability examination for his back disability. The Veteran reiterated that he observed back pain during service. He added that it progressed after service and, now, he is unable to sit or stand for prolonged periods of time, observes pain when washing dishes, as well as observes pressure when sitting. See October 2019 VA DBQ Back at 2. The examiner noted the diagnosis of lumbosacral strain. Id. Then the examiner prepared a medical opinion wherein she concludes that the Veteran’s back disability is not related to his service. See October 2019 VA Medical Opinion at 3. The examiner acknowledged the Veteran complained of back pain during service. The examiner also acknowledged newly submitted records show complaints of back pain after service, around 1999. But the examiner emphasized that those records do not address the presence of a back condition. She added that there is no history of any post-service injuries as well. Id. In December 2020, the VA received a private medical evaluation by M.W., MD, who notes he has reviewed the Veteran’s entire claim file and spoke to the Veteran. See July 2020 Private Medical Opinion of M.W., MD, at 1. Dr. M.W. noted the diagnoses of repetitive strain and lumbar spondylosis of his lumbar spine and sacralization of the L5. Also, lumbosacral strain. Id. at 3. Dr. M.W. opined that the Veteran’s low back disability is more likely than not related to his service. Id. at 3. Dr. M.W. explained that the record reflects there is no history of back conditions prior to entering service, but there is a record of complaints of low back pain during and after service: he noted the record shows at least six visits to sick-call during service, (in August 15, 1984; January 29, 1986, March 27, 1990; May 31, 1990; June 21, 1990; and October 23, 1990). Also, the Veteran reported that the back pain persisted through service and it limited the type of work he could do. Dr. M.W. acknowledged and considered the March 2016 and October 2019 VA medical opinions that concluded the Veteran’s back disability is not related to service. Dr. M.W. indicated those opinions were based in an incomplete review of the record. That is, those examinations noted the Veteran had not been treated for back conditions following service. But, during his review, he found evidence of such treatment following service. He added that the Veteran confirmed observing pain at his back following service. Id. Turning to the Veteran’s claim for disability compensation, the first issue is whether the Veteran has a current disability. All the medical evaluations submitted during the appeal period find the Veteran has a lumbar sprain, diagnosed as lumbosacral strain. Thus, the record reflects a diagnosed back disability. See March 2016 VA DBQs at 1; October 2019 VA DBQ at 2; July 2020 Medical Opinion of M.W., MD, at 3. The next issue is whether the Veteran has an in-service incurrence or aggravation of a disease or injury. The Board finds the evidence shows several injuries occurred during service. The Veteran’s service medical records identify several injuries during service: in July 1982, he injured his right knee doing physical training as part of his basic training; in June 1984, he injured the same knee playing basketball; in August 1984, he is believed to have pulled a muscle in his lower back; a doctor noted the Veteran had a back strain sometime in 1985; in March 1990, he complained of back pains due to a fall. See July 30, 1982, STR by C.P.W; June 23, 1984, and August 15, 1984, STR by J.P.C.; January 29, 1986, Report of Medical History at 2. Although those records report the Veteran’s lay statements and observations, the Board finds his service medical records credible. When he reported those symptoms, he had personal knowledge of the observed pain and the activities he engaged in before observing pain. So, his reports are competent to support an in-service injury. Layno, 6 Vet. App. at 469. Also, reports to medical providers in the course of obtaining treatment are generally held to be reliable; so, the Board finds them credible and assigned them great weight in favor of an in-service injury or incurrence. The Board notes this finding applies to all the injuries reported in those records, to include a basketball injury in 1984, a back strain around 1985, and a fall in 1990. This is because the Veteran has not limited his assertions to any particular injury. As a result, the Board has considered all the in-service injuries reasonably raised by the record. The Veteran has also asserted injuries stemming from physical activities that are part of general soldiering, such as ruck marching and carrying heavy loads. See March 2016 VA DBQ at 2. The Veteran has personal knowledge of the activities her performed before he observed pain at his back. So, his reports are competent to support an in-service injury. Layno, 6 Vet. App. at 469. Even though his DD214 shows he was not in an occupational specialty where those activities are part of his regular duties, as a Marine, he is likely to have performed those activities, at least, occasionally. So, the Board finds his lay statements credible and assigned it some, but not significant, weight towards an in-service injury. In this case, the Board finds the evidence weighs in favor of finding there were several in-service injuries. The Veteran credibly asserted he incurred in-service injuries during service. And his statements are supported by his service medical records. Those records show several injuries, to include a basketball injury in 1984, a back strain around 1985, and a fall in 1990. So, the Board finds those injuries occurred while in-service. The next issue is whether there is a nexus between the Veteran’s back disability and service. Resolving doubt in the Veteran’s favor, the Board finds the evidence supports finding there is a nexus. The Veteran has not attributed his back disability to any one of the particular in-service injuries discussed above; he spoke of injuries, generally. Nor is he qualified to opine whether one, or more, of those injuries caused his back disability. Jandreau, 492 F.3d at 1377. Nor is the Board. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). So, the issue of a nexus was decided based on the medical evidence of record. Although the Veteran’s service medical records note injuries and diagnoses, like chronic back pain, none of them are of a kind that a nexus could be presumed, such as arthritis. 38 C.F.R. § 3.309(a). So, the Veteran’s service medical records were of little probative value towards establishing a nexus. The March 2016 and October 2019 VA disability examinations weighed against a nexus. But, for the reasons explained below, the Board finds those examinations of little to no probative value. As to the March 2016 VA disability examination, the Board acknowledges the examiner did not have a complete medical history before him when he concluded there is no nexus. At that time, there were no medical records showing treatment for a back condition for the period between 1991 (when the Veteran separated from service) and 2014; nor did the Veteran describe the treatment he received during that time. So, the examiner concluded the Veteran had not received treatment for his back condition between 1991 and 2014. But that turned out to be inaccurate; evidence submitted after this examination showed the Veteran did receive treatment for a back condition during that period. Because the examiner based his conclusion on an inaccurate account of the Veteran’s past medical history, this opinion could not be considered. Nievez-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2006). The examiner who prepared the October 2019 VA medical opinion did consider the newly submitted evidence; however, it is not clear to the Board whether she fully considered those records. She acknowledged the Veteran’s statements and considered the records he provided. So, she was cognizant of the relevant aspects of the Veteran’s medical history. Nievez, 22 Vet. App. at 301. Although she was aware of his medical history, she did not explain why documented complaints of back pain following service were not considered. She emphasized there is a large number of complaints of back pain following service and dismissed them because they did not note specific back conditions. Without more, it is not clear if she considered whether she considered if his complaints related to his in-service injuries, notwithstanding the lack of specified conditions. Nor is it clear if consideration of those complaints would have changed the outcome of her conclusion. Since she did not specify why she dismissed his post-service complaints of back pain, the Board is unable to evaluate the impact they had on her decision. As a result, the probative value of her opinion was diminished, and it was assigned little to no probative weight. Nievez, 22 Vet. App. at 301. The July 2020 private medical opinion, by Dr. M.W., weighed in favor of a nexus. As a medical doctor, he is qualified to opine on the likelihood of a nexus. Also, he noted he reviewed the Veteran’s file and provided an extensive recitation of the Veteran’s medical history, from his entry into service through July 2020; thus, the Board finds he was cognizant of the relevant aspects of the Veteran’s medical history. Nievez, 22 Vet. App. at 301. Although Dr. M.W. opined the Veteran’s current back disability is related to his service, he did not specify it was due to one or more injuries the Veteran reported. Nor explain why. Instead, Dr. M.W. indicated the cumulative amount of complaints during service and the consistency of complaints following service supports a causal relationship between them. Even though he does not discuss the Veteran’s particular injuries, his focus on the Veteran’s complaints of pain is sufficient for the Board is able to evaluate whether the data he relied on connects to his conclusion. Nievez, 22 Vet. App. at 301. So, the Board assigned it some, but not significant, probative weigh in favor of a nexus. In this case, the evidence is, at least, approximately balanced on the issue of a nexus. Weighing against the claim are the March 2016 and October 2019 VA disability examinations. The March 2016 examination was not considered. And the October 2019 opinion was of little probative value because the Board was unable to evaluate the reasons the examiner’s conclusion. Weighing in favor of the claim is the more probative July 2020 private medical opinion that concluded there is a nexus between the Veteran’s back disability and service. So, there is, at least, an approximate balanced of evidence on this issue. Under these circumstances, doubt should be resolved in the Veteran’s favor. Gilbert, 1 Vet. App. at 54. In sum, the Veteran has established he has a current back disability, an in-service injury or incurrence, and a nexus between his disability and service; therefore, he is entitled to service connection under 38 C.F.R. § 3.303(a). Accordingly, service connection is granted for his diagnosed lumbar strain. 2. Entitlement to service connection for degenerative joint disease at the right knee. The Veteran contends his diagnosed right knee degenerative joint disease (right knee disability) is related to his service. The question for the Board is whether there is sufficient evidence to find that the Veteran’s right knee disability is related to his service. For the reasons discussed below, the Board concludes that the evidence supports a grant of service connection. Another way a Veteran can establish service connection is by satisfying the test for disability compensation for chronic diseases set forth in 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331, 1334 (2013). To satisfy that test the Veteran must (1) have a chronic disease listed under 3.309(a) and (2) that disease must have been “shown in service.” Id. at 1335. As to (1), arthritis, which includes degenerative joints disease, is listed under 38 C.F.R. § 3.309(a). As to (2), 38 C.F.R. § 3.303(b) equates “shown in service” with a reliable diagnosis of the chronic disease while in service. Walker, 708 F.3d at 1335. If the Veteran satisfies the test for disability compensation for chronic diseases in 38 C.F.R. § 3.303(b), the Veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability is sought. Id. at 1336. If the Veteran cannot demonstrate he had a chronic disease during service or during the applicable presumption period, a substitute way of showing in-service incurrence is if he demonstrates continuity of symptomatology. Savage v. Gober, 10 Vet. App. 488, 496-98 (1997). To do so, the Veteran must show his condition was (1) “noted during service,” and (2) evidence that relates the Veteran’s current disability to the continuity of symptomatology demonstrated since service. Id. In March 2016, the Veteran underwent a VA disability examination for his knee disabilities. The Veteran reported he observed pain in his left and right knees during service. He reported he injured his right knee while participating in sports related activities during service. As for his current symptoms, he reports his knee disabilities interfere with his ability to stand or walk for prolonged periods of time. See March 2016 VA DBQ at 2. The examiner noted the diagnosis of degenerative joint disease at the right knee. Id. at 1. Then the examiner concluded the Veteran’s right knee disability is not related to his service. The examiner acknowledged the Veteran had been treated for right knee pain in 1983 and 1984, but a 1986 record noted his right knee pain resolved. The Veteran found support for that record by the presence of one complaint of right knee pain from 1986 to 1990, when the Veteran ended his first period of service. He added that there is an absence of objective evidence of treatment for a right knee condition following service until 2014. Id. at 12. The examiner considered the Veteran’s VAMC records showing treatment for a right knee condition in 2014, but referred to a record dated May 5, 2014, that notes the Veteran’s right knee pain resolved. So, the examiner concluded it was an acute condition. Id. The Board notes the Veteran’s claim was remanded for a new VA disability examination that considered newly submitted evidence showing complaints of knee pain between 1991 and 2014. Also, the VA examiner was asked to consider the Veteran’s report of a football injury before entering service. See July 26, 1982, Service Treatment Record by J.F.C. In October 2019, the Veteran underwent another VA disability examination for his right knee disability. The Veteran reported that before entering service, he felt pain in his knee while playing football; he reported he was not diagnosed with a knee or leg condition. He also reported injured his right knee during bootcamp. Then, in 1983, he was placed on limited duty due to knee pain. He added that the pain in his knee has progressed; now, he observes stiffness in both knees while sleeping and pain that interferes with standing. See October 2019 VA DBQ s at 2, 9. The examiner noted the diagnosis of degenerative arthritis right knee. Id. at 2. Then the examiner prepared a medical opinion wherein she concludes that the Veteran’s right knee disability is not related to his service. See October 2019 VA Medical Opinion at 3, 4. The examiner acknowledged the Veteran complained of right knee pain during service, in 1984 and 1985, but emphasized that a 1986 record notes his right knee pain resolved. She also noted there is an absence of objective evidence that the Veteran was treated for right knee pain, from discharge to 2014. Id. The examiner considered the Veteran’s VAMC records showing treatment for a right knee condition in 2014, as well as meniscal tears in both knees. She indicated that the history of the injury associated with the complaints is unknown. She also emphasized a VAMC record dated May 5, 2014, that notes the Veteran’s right knee pain resolved. So, the examiner concluded it was an acute condition. Id. The examiner was asked to opine on the likelihood that the Veteran’s right knee disability preexisted service. Without explaining her reasons for concluding the Veteran’s right knee disability pre-existed service, she noted “[w]hile he did have additional right knee complaints years later, the fact that the right knee issues had ‘resolved’ as of 1986, would indicate that his pre-existing right knee injury was ‘less likely than not aggravated by service.’” Id. at 5. In December 2020, the VA received a private medical evaluation by M.W., MD, who notes he has reviewed the Veteran’s entire claim file and spoke to the Veteran. See July 2020 Private Medical Opinion of M.W., MD, at 1. The Veteran reported that, following discharge from service, he observed knee pain that progressively worsened. Id. at 2. And when he left the military, he was unable to do any work which required squatting and kneeling and branding. Id. at 4. He reported that he did not seek medical attention after leaving service; he tried to alleviate the pain with over-the-counter medication and bracing. But the pain persisted. Id. at 2. Dr. M.W. noted the diagnoses of lateral meniscal tear and degenerative arthritis of the lateral compartment. Id. at 4. Dr. M.W. opined that the Veteran’s right knee disability is more likely than not related to his service. Id. Dr. M.W. explained that the record reflects there is no history of right knee conditions prior to entering service, but there is a record of complaints of right knee pain during and after service: he noted the record shows at least six visits to sick-call during service, (in July 30, 1982; June 25, 1984; July 6, 1984; August 15, 1984; June 29, 1986; and November 6, 1990). Id. He added that the Veteran’s complaints of right knee pain in July 30, 1982, as early as June 25 and July 6, 1984, are consistent with meniscal pathology. Id. at 1. Dr. M.W. indicated he relied on the Veteran’s reports of persistent right knee pain since service. Id. at 1. And added that the symptoms the Veteran reported in October 20005, to D.T., MD, were similar to the symptoms described during service. Id. at 2. Dr. M.W. acknowledged and considered the March 2016 and October 2019 VA medical opinions that concluded the Veteran’s right knee disability is not related to service. He explained that the record reflects a long history of complaints of right knee pain during service. He added that degenerative changes of the knee stemming from injuries develop gradually. He indicated that these factors led him to conclude it is as likely as not that the Veteran’s right knee disability is related to his service. A. Entitlement to service connection based on having a chronic disease during service or within one year from separation from service. The first issue is whether the Veteran has a chronic disability listed under 38 C.F.R. § 3.309(a). The record reflect that Veteran has been diagnosed with degenerative joint disease at the right knee (right knee disability). See March 2016 VA DBQ at 1; October 2019 VA DBQ at 2. Degenerative joint disease is a form of arthritis; so, the record reflects a chronic disability listed under § 3.309(a). The next issue is whether the Veteran demonstrated his right knee disability was shown in service or within one year following service. The Board finds the evidence does not support the presence of arthritis during service or a year after service. The Board notes it has found the Veteran had several in-service injuries, to include a basketball injury in 1984, a back strain around 1985, a fall in 1990, and he hit his right knee on the bed of a truck that same year. The Board finds the Veteran’s lay statement of pain during service, credible. The Veteran is competent to report observations, like pain. Layno, 6 Vet. App. at 469. Also, the activities that he engaged in before sensing pain. Id. Here, he reported observing pain during most of his military career. See July 2020 Medical Opinion by M.W., MD. at 2. And he associated that pain with several injuries during service, to include during physical training and sports. See March 2016 VA DBQ at 2; October 2019 VA DBQ at 2. The Veteran’s service medical records support and enhance the credibility to the Veteran’s statements. There are several records noting of complaints of right pain throughout his service, from basic training, in 1982, to November 1990, shortly before he left service. Since the statements to medical providers are generally found reliable, these documents enhance the probative value of the Veteran’s lay statement of pain during service. See July 30, 1982, STR by C.P.W; June 23, 1984, STR by J.P.C.; July 6, 1984 STR; August 15, 1984, STR by J.P.C.; January 29, 1986, Report of Medical History at 2; November 16, 1990 STR by R.W.B. PA-C. A factor weighing against a finding of chronicity during service is the lack of medical evidence that links any of his in-service injuries to the presence of arthritis while in service. Medical evidence is required to provide a causal nexus between an in-service injury and arthritis. Savage, 10 Vet. App. 488 at 495-496. None of the medical opinions for the right knee claim link any specific injury to arthritis; The March 2016 and October 2019 VA medical opinions do not discuss particular injuries at all. And the July 2020 private opinion discusses in-service injuries, generally. So, even though the Veteran’s reports of pain have been found credible, they do not establish a disease entity or diagnosis that is not subject to legitimate question. Walker, 708 F.3d at 1335-36. In this case, the evidence weighs against finding the Veteran had a chronic disease in service. Although the Veteran was treated for knee pains during service, there is no medical evidence that demonstrates the condition was chronic during service. Nor within one year following service. B. Entitlement to service connection based on continuity of symptomatology. Since the Veteran can still obtain the benefit of 38 C.F.R. § 3.303(b) on the basis of continuity of symptomatology, the next question issue is whether the Veteran’s right knee disability was shown in or noted in service. The Board finds the evidence supports a finding that the Veteran’s right knee disability was noted during service. The Board notes it has found the Veteran’s lay statements of pain competent and credible. And because symptoms, not treatment or diagnoses, are the essence of continuity of symptomatology—the Veteran’s credible statements are sufficient to satisfy the noting requirement. Savage, 10 Vet. App. at 496-98. The next issue is whether the Veteran has provided evidence that relates the Veteran’s current disability to the continuity of symptomatology demonstrated since service. The Board finds the evidence links his right knee disability to the continuity of symptomatology demonstrated since service. The Board finds the Veteran’s lay statement of continuous pain following service credible. The Veteran is competent to report observations of pain following service. Layno, 6 Vet. App. at 469. Here, he reported he observed pain since service, to include pain that limited the jobs he performed. See July 2020 Medical Opinion by M.W., MD, at 2, 4. And the private medical records he submitted support his assertions; those records, beginning in 2000, show complaints and treatment for right knee pain. As to the period between 1991 and 2000, the Veteran provided a credible explanation for the absence of medical records showing complaints of pain or treatment for a right knee condition. The Veteran has personal knowledge of the reasons he did not seek out medical attention following service. So, he is competent to report it. Layno, 6 Vet. App. at 469. Here, he reported that he did not seek medical attention right away and tried to alleviate the pain himself through over the counter medication and bracing. Id. at 2. Considering he did not assert he experienced incapacitating pain following service, it is plausible to believe he tried to alleviate the pain in the manner asserted. So, the Board finds his statement credible and assigned it significant weight towards a finding of continuous symptoms. Although the Veteran is competent to report those symptoms, he is not competent to diagnose an etiological link between those symptoms and his right knee disability. Jandreau, 492 F.3d at 1377. The July 2020 medical opinion is medical evidence that links the Veteran’s continuous symptoms to his diagnosed right knee disability. The Board notes it has found the examiner was cognizant of the relevant aspects of the Veteran’s past medical history when he rendered his conclusion. Nievez, 22 Vet. App. at 301. The examiner explained that the Veteran’s injuries caused gradual degenerative changes, which are related to the symptoms he observed following service. See July 2020 Medical Opinion by M.W., MD, at 2. His explanation is sufficient to evaluate whether the data he relied on connects to his conclusion. Nievez, 22 Vet. App. at 301. So, the Board assigned it significant weight towards finding the symptoms he observed following service are linked to the one he observed during service. The Board acknowledges the March 2016 and October 2019 VA Medical Opinions weighed against a grant of service connection. For reasons explained before, the March 2016 opinion was found to be of no probative value because the examiner provided an inaccurate account of the Veteran’s past medical history. The VA examiner who prepared October 2019 opinion also provided an inaccurate account of the Veteran’s past medical history. She emphasized the Veteran had complained of right knee pain during service on only once occasion, between 1986 and 1990. See October 2019 VA Medical Opinion at 3. The record reflects he visited sick-call for complaints of right knee pain more than once. Also, the examiner noted the Veteran was not treated for a right knee condition until 2014. Id. But the record available to her included private medical records showing treatment for right knee pain as early as 2000. So, it is apparent to the Board that the examiner did not have an accurate account of the Veteran’s past medical history. Nievez, 22 Vet. App. at 301. And it could not be considered. The Board recognizes the examiner also opined on the likelihood that the Veteran’s right knee disability preexisted service. There are several reasons her opinion could not be considered. First, no deformities were noted on his enlistment exam. 38 C.F.R. § 3.304(b). And considering his sports injuries before service did not result in any diagnosed conditions, it does not constitute evidence that is sufficient to rebut the presumption of soundness. See October 2019 VA DBQ at 2. Second, the examiner did not provide an opinion that applies the appropriate analysis to rebut the presumption of soundness. The examiner asserted, but did not explain, why the Veteran’s right knee disability pre-existed service. It is a high standard that requires a rationale that explains her conclusion. Since there is not one on this question, her opinion could not be assigned any probative weight. For the same reason, the Board could not consider her conclusion that the Veteran’s right knee disability was not aggravated by his service. Third, the examiner has been found to have an incomplete understanding of the Veteran’s past medical history; so, even if her opinion was sufficient, it could not be considered. Returning to the issue of continuous symptoms, the Board finds the evidence weighs in favor finding the Veteran had continuous symptoms of arthritis since service. His assertions of continuous symptoms since service, to include the period of time where there is an absence of medical records, was found credible. And he provided medical evidence that links his diagnosed degenerative joint disease at the right knee to injuries incurred during service. In light of the evidence, any doubt was resolved in the Veteran’s favor. Gilbert, 1 Vet. App. at 54. In sum, the Veteran has established entitlement to service connection under 38 C.F.R. § 3.303(b) based on continuity of symptomatology. Accordingly, service connection is granted for his diagnosed degenerative joint disease at the right knee. REASONS FOR REMAND 1. Entitlement to service connection for a left knee disability is remanded. Although the Board regrets the delay, the Veteran’s left knee disability claim, to include residuals of a left knee arthroscopy, medial meniscal tears, Ganglion Cyst ACL must be remanded for a new medical opinion before the Board is able to decide on the merits. Another medical opinion is required because neither the March 2016, October 2019, nor the July 2020 medical opinions are sufficient to decide the Veteran’s claim. The VA has a duty to assist claimants and must make “reasonable efforts to assist a Veteran in obtaining evidence necessary to substantiate the claimant’s claim for benefits.” 38 U.S.C. § 5103A(a)(1). Part of that duty to assist includes obtaining a medical opinion when an “opinion is necessary to make a decision on the claim.” 38 U.S.C. § 5103A(d)(1). The VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease, occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability; but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. 38 U.S.C. § 5103A(d)(2); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). In March 2016, the Veteran underwent a VA disability examination for his left knee disability. The Veteran reported he experienced pain in his left and right knees during service. He did not attribute his left knee pain to a specific traumatic event. See March 2016 VA DBQ at 2. The examiner noted the diagnosis of residuals of a left knee arthroscopy. Id. The examiner also noted the Veteran does not have arthritis at the left knee. Id. at 10. Then, the examiner concluded the Veteran’s left knee disability is not related to his service. His opinion was, at least in part, based on the absence of objective evidence of treatment for a left knee condition following service until 2003. Id. at 12. The Board notes it remanded the claim because the Veteran submitted medical records showing he had been treated for complaints of knee pains before 2003. In October 2019, the Veteran underwent another VA disability examination for his left knee disability. The Veteran reported that, in 1983, he was placed on limited duty due to knee pains. See October 2019 VA DBQ at 2. The examiner noted the Veteran does not have arthritis at the left knee. Id. at 16. Then the examiner prepared a medical opinion wherein she concluded that the Veteran’s left knee disability is not related to his service. See October 2019 VA Medical Opinion at 3, 4. In her rationale, she explained there is an absence of objective evidence that the Veteran was treated for left knee pain, from discharge to 2003. Id. In December 2020, the VA received a private medical evaluation by M.W., MD. The Veteran reported that, following discharge from service, he observed knee pain that progressively worsened. See July 2020 Private Medical Opinion of M.W., MD, at 2. And he did not seek medical attention for some time. Id. Dr. M.W. noted the diagnoses of recurrent medial meniscal tears, Ganglion Cyst ACL, and arthritis of the left knee. Id at 4. Dr. M.W. opined that the pathology from the November 9, 2005, surgery on the Veteran’s left knee indicates a chronic condition. Id. at 2. He also opined that the Veteran’s left knee disability is more likely than not related to his service. Id. at 4. He explained that the Veteran did not have a left knee condition before service but complained of knee pains during service. Dr. M.W. indicated the Veteran’s VAMC records noting complaints of left knee pain support the conclusion that the Veteran’s left knee worsened over time. Id. at 4. A search of the Veteran’s VAMC records did not reveal a finding of arthritis at the Veteran’s left knee. And, other than the July 2020 opinion of Dr. M.W., the medical records submitted by the Veteran do not show any findings of arthritis at the left knee. Turning to the Veteran’s claim for disability compensation, the Board finds the March 2016, October 2019, and July 2020 medical opinions insufficient to evaluate the Veteran’s left knee claim. Starting with the VA medical opinions, the examiner who prepared the March 2016 opinion based her opinion on an inaccurate account of the Veteran’s past medical history. And, as explained before, the examiner who prepared the October 2019 opinion also based her it on an inaccurate account of the Veteran’s past medical history. As to the July 2020 private medical opinion, although Dr. M.W. noted the diagnosis of left knee arthritis, the record does not support it. He did not indicate the basis for that diagnosis. The VA disability examinations of record specifically noted Veteran does not have arthritis at the left knee. See March 2016 VA DBQ at 10; October 2019 VA DBQ at 16. And the record does not show and findings of arthritis at the left knee. Dr. M.W.’s failure to support his diagnosis of arthritis affects the Board’s evaluation of his opinion. The Board acknowledges he rendered a positive opinion, but he did not specify which of the three noted diagnoses are related to the Veteran’s service. He noted the Veteran has three left knee conditions: meniscal tears, ganglion cysts, and arthritis at the left knee. Then, without addressing any particular diagnosis, he linked the Veteran’s post-service complaints of left knee pains to service. See July 2020 Private Medical Opinion of M.W., MD, at 4. In order to assign this opinion any probative weight, the Board would have to infer all, or some, of the diagnosis are related to his service. Considering the diagnosis of arthritis is at question, the Board cannot infer all the listed diagnoses are related to his service. And the Board is not qualified to decide if some of the listed diagnoses are related to his service. Colvin, 1 Vet. App. at 175. So, the Board could not decide the Veteran’s claim on this opinion. Because the March 2016, October 2019, and July 2020 medical opinions are not sufficient for the Board to evaluated and decide the Veteran’s left knee claim, a new VA disability examination is warranted. McLendon, 20 Vet. App. 79, 81 (2006). The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his (1) residuals of a left knee arthroscopy, (2) ganglion cysts ACL, and (3) meniscal tears. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: a. Is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s (1) residuals of a left knee arthroscopy or (2) left knee ganglion cysts or (3) left knee meniscal tears was incurred in or is otherwise related to his service? b. Is it at least as likely as not (i.e. a 50 percent probability or greater) that the (1) residuals of a left knee arthroscopy or (2) left knee ganglion cysts or (3) left knee meniscal tears was caused by the Veteran’s service-connected right knee disability? c. Is it at least as likely as not (i.e. a 50 percent probability or greater) that the (1) residuals of a left knee arthroscopy or (2) left knee ganglion cysts or (3) left knee meniscal tears was aggravated by the Veteran’s service-connected right knee disability? d. If the Veteran is found to have arthritis, is it at least as likely as not that it (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? The examiner, in coming to his or her conclusion, is asked to comment on the following: i. Discuss the Veteran’s service medical records showing he was treated for left knee pain on July 6, 1984. ii. Discuss the Veteran’s complaints of right knee pains during service, to include on July 30, 1982; July 6, 1984, July 25, 1984; August 15, 1984; January 29, 1986; March 27, 1990; and November 6, 1990. iii. Discuss the Veteran’s service medical records dated July 30, 1982, that show knee injuries during basic training; July 23, 1984, showing he injured a knee while playing basketball; January 29, 1986, noting a right knee sprain; November 16, 1990, noting the Veteran hit his right knee on the bed of a truck. iv. Discuss the private medical records following service showing treatment for a left knee condition, to include records dated August 23, 2000; December 15, 2000; July 7, 2003; October 11, 2005; November 9, 2005; and May 13, 2009. v. Address the July 2020 opinion by M.W., MD, that opines the Veteran’s (1) residuals of a left knee arthroscopy, (2) left knee ganglion cysts, (3) left knee meniscal tears, and (4) left knee arthritis are related to service. vi. Discuss the Veteran’s lay assertions of knee pain following service. vii. If the Veteran’s left knee disorder(s) include a diagnosis of arthritis, opine whether the left knee arthritis is at least as likely as not manifested within a year after an active-service period, or whether the record reflects continuing symptoms of arthritis since service. Explanations for all opinions must be provided. While providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dean, Michael S. 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.