Citation Nr: 21012913 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 10-33 759 DATE: March 5, 2021 ORDER Entitlement to service connection for degenerative joint disease of the right shoulder is denied. Entitlement to service connection for diverticulosis is denied. Entitlement to service connection for small bowel obstruction associated with diverticulosis is denied. Entitlement to service connection for acid reflux gastroenteritis is denied. Entitlement for service connection for a bilateral eye disability, specifically meibomian gland dysfunction, is granted. Entitlement to service connection for degenerative joint disease of the right knee is denied. Entitlement to service connection for a thoracolumbar spine disorder is denied. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had a right shoulder disability at any time during or approximate to the pendency of the claim. 2. The Veteran’s diverticulosis is not secondary to service-connected left knee disability, including medication taken for the disability, and is not otherwise related to an in-service injury or disease. 3. The Veteran’s small bowel obstruction associated with diverticulosis is not secondary to service-connected left knee disability, including medication taken for the disability, and is not otherwise related to an in-service injury or disease. 4. The Veteran’s acid reflux gastroenteritis is not secondary to service-connected left knee disability, including medication taken for the disability, and is not otherwise related to an in-service injury or disease. 5. A bilateral eye disability, specifically meibomian gland dysfunction, had onset during service. 6. The Veteran’s degenerative joint disease of the right knee was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 7. The Veteran’s thoracolumbar spine disorder was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for degenerative joint disease of the right shoulder are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for diverticulosis due to service or medical for service-connected left knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for small bowel obstruction due to service or medication for service-connected left knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for acid reflux gastroenteritis due to service or medication for service-connected left knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for service connection for a bilateral eye disability, specifically meibomian gland dysfunction, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for degenerative joint disease of the right knee are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for service connection for a thoracolumbar spine disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 1959 to August 1964 and from May 1965 to February 1983. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from February 2008 and May 2009 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The appeal was remanded for further development in June 2015 and March 2019. Additional evidence, consisting of private treatment records was received following the issuance of the August 2020 supplemental statement of the case and certification of the appeal to the Board. The additional evidence is cumulative of evidence already of record, such that neither a supplemental statement of the case (as set forth in 38 C.F.R. § 19.37 (a)), nor a solicitation of a waiver (as set forth in 38 C.F.R. § 20.1304 (c)), is necessary. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900. 38 U.S.C. § 7107 (a)(2). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for degenerative joint disease of the right shoulder The Veteran seeks service connection for degenerative joint disease of the right shoulder. He contends that a right shoulder disability arose during service, and has persisted to the present. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Veteran was afforded a VA examination in March 2017. The Veteran reported onset of symptoms between 1977 and 1982. He reported right shoulder pain in the rhomboid area, improved by massage, use of a TENS unit, and a lidocaine patch over the area. He reported that it hurt to raise his arm all the way over his head. X-ray imaging of the right shoulder revealed no fracture or other significant bone or soft tissue abnormality. No degenerative joint disease or arthritis was noted. In July 2018, the Veteran sought treatment for low back pain. As part of the examination, treatment providers noted a history of right shoulder osteopenia. The Board concludes that the Veteran does not have a current diagnosis of a right shoulder disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board is mindful of Saunders v. Wilkie, in which the Federal Circuit explained that where pain alone results in functional impairment that affects earning capacity, even if there is no identified underlying diagnosis, it can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). While the Veteran has credibly reported right shoulder pain, there is no current evidence (i.e. since the claim was filed) showing the pain has been so severe as to cause functional impairment that affects his earning capacity. Of note, the March 2017 VA examination report shows that the Veteran reported pain if he raised his arm above his head. This does not demonstrate occupational functioning is impaired by his shoulder pain. The Veteran has not otherwise asserted, nor provided objective evidence, that his shoulder pain results in functional impairment that affects his earning capacity. Based on the foregoing, the Board does not find that the Veteran’s shoulder pain rises to the level of a disability under Saunders. The March 2017 VA examiner evaluated the Veteran and determined that, while he experienced subjective symptoms of right shoulder pain and tenderness, he did not have a diagnosis of degenerative joint disease or arthritis. While private treatment providers stated in a July 2018 note that the Veteran had osteopenia of the right shoulder, osteopenia is a medical term to refer to any decrease in bone mass below normal. See Dorland’s Illustrated Medical Dictionary, 1336 (30th ed. 2003). There is no evidence in the record that the Veteran has ever been diagnosed with a disability due to or otherwise related to the osteopenia or that he has an underlying disease associated with osteopenia. As noted, the record is absent a competent diagnosis of degenerative joint disease or arthritis. While the Veteran believes he has a current diagnosis of degenerative joint disease, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. In the absence of proof of a present disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There is no doubt to be resolved. Service connection for a right shoulder condition is not warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for diverticulosis 3. Entitlement to service connection for small bowel obstruction associated with diverticulosis 4. Entitlement to service connection for acid reflux gastroenteritis The Veteran seeks service connection for several gastrointestinal disabilities, including diverticulosis, small bowel obstruction, and acid reflux gastroenteritis. He asserts that his gastrointestinal disabilities are related to treatment for gastrointestinal problems during active service. Alternatively, he contends that his gastrointestinal disabilities are proximately caused by or aggravated by medication taken for his service-connected left knee disability. The question for the Board is whether the Veteran has a gastrointestinal disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Service treatment records show the Veteran sought treatment for gastrointestinal issues during active service. In October 1966, the Veteran sought treatment for stomach cramps. He also reported continuous bowel movements. Treatment providers assessed gastroenteritis. At an October 1982 clinical visit, the Veteran reported indigestion and occasional gas, which he self-treated with antacids. Post-service treatment records show the Veteran sought treatment for abdominal pain in August 2000. A CT scan demonstrated moderate sigmoid diverticulitis with a probable micro perforation. He was also noted to develop a small bowel obstruction that was felt to be due to inflammation. At his discharge, providers diagnosed diverticulitis, small bowel obstruction, and hypertension. In August 2005, the Veteran underwent a colonoscopy for diverticulitis. Examination of the sigmoid colon and descending colon contained a few scattered diverticula. In September 2016, the Veteran presented to the emergency room with abdominal pain. He reported that he had not had a bowel movement in the past few days, and had a history of constipation and diarrhea. Treatment providers diagnosed sigmoid diverticulitis. The Veteran was afforded VA examinations for small bowel obstruction and diverticulosis in March 2017. The examiner opined that the Veteran had no current diagnoses. The Veteran was afforded a VA examination for acid reflux and gastroenteritis in March 2017. The examiner found that this condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, because there were no related complaints cited in his active duty service treatment records. However, as noted in the remand, the service treatment records showed the Veteran was treated on several occasions for gastroenteritis. In February 2020, a VA examiner offered an addendum opinion regarding the Veteran’s diverticulosis, status post small bowel obstruction, and acid reflux. The examiner opined that the current gastrointestinal disorders were less likely than not incurred or caused by the claimed in-service gastrointestinal complaints. The examiner noted that the Veteran was treated for gastroenteritis in the military on several occasions. However, she explained that the evidence demonstrates this gastroenteritis to be acute, self-limiting, and resolved in nature. The Veteran in this case has no diagnosis of gastroenteritis listed on the problem list from 1998 to the present, to validate a recurrence. She indicated that per peer-reviewed medical evidence, gastroenteritis affects the stomach and intestines, while diverticulosis and acid reflux in this Veteran are related specifically to the sigmoid and distal descending colon. Further, she noted that the risk factors for diverticulosis is aging, obesity, smoking, and a diet high in animal fat and low in fiber. She stated that diverticulitis is common after 40. She concluded that a nexus is not established between the current diagnoses of diverticulosis, status post small bowel obstruction, gastrointestinal reflux disease, and the Veteran’s military service. The examiner also opined that it was less likely than not the gastrointestinal disorders were incurred, caused by, or aggravated by medications taken for service-connected knee disorder. She explained that gastroesophageal reflux disorder occurs when acidic stomach juices back up from the stomach into the esophagus and irritate the lining. She noted that certain medications can irritate the lining of the esophagus or increase severity of acid reflux. She opined that the evidence does not support that the NSAIDs or opioids for the left knee disorder account for the Veteran’s gastrointestinal reflux disorder symptoms, since he was on multiple medications for medical conditions unrelated to the left knee which could cause severe reflux. In particular she noted the Veteran has been prescribed anticholinergics, antibiotics, and prednisone to treat COPD [a nonservice-connected disability] which also impact his gastrointestinal reflux disorder symptoms negatively. She further explained that peer reviewed medical evidence does not establish any correlation, nexus, or aggravation between the diagnosed diverticulosis and small bowel obstruction and the medications taken for the left knee disorder. Thus, she concluded that it is less likely than not the Veteran’s gastrointestinal disabilities are proximately caused by or aggravated by medications taken for the service-connected left knee disorder. The Board concludes that, while the Veteran has current diagnoses of acid reflux, diverticulosis, and status post small bowel obstruction, and evidence shows that he received treatment during active service for gastroenteritis, the preponderance of the evidence weighs against finding that the currently diagnosed gastrointestinal disorders began during service or are otherwise related to an in-service injury, event, or disease. Treatment records show the Veteran was not diagnosed with diverticulosis until 1998, years after his separation from service. While the Veteran is competent to report having experienced symptoms of gastrointestinal issues since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of diverticulosis. In a February 2020 clarifying addendum opinion, a VA examiner opined that the Veteran’s gastrointestinal disorders, including diverticulosis, status post small bowel obstruction, and acid reflux, are not at least as likely as not related to an in-service injury, event, or disease, including treatment for gastroenteritis during active service. The gastroenteritis during active service had resolved, and that it affected a different part of the digestive system then the Veteran’s later noted diverticulosis and small bowel obstruction. She also opined that the Veteran’s gastrointestinal disabilities, including acid reflux, are less likely than not proximately caused or aggravated by medications for the left knee disability. With respect to acid reflux, she explained that the Veteran was on numerous medications for non-service-connected disabilities that negatively affected his acid reflux disease, and that there was no documentation in the medical records regarding a permanent worsening of gastrointestinal reflux disease from the opioids or NSAID’s for the left knee. She further explained that peer reviewed medical evidence did not establish any correlation, nexus, or aggravation between the diagnosed diverticulosis or small bowel obstruction and the medications taken for the left knee disability. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran believes his gastrointestinal disabilities are related to an in-service injury, event, or disease. The Veteran also believes his gastrointestinal disabilities are proximately due to or the result of/aggravated beyond its natural progression by medications taken for a service-connected disability. In the February 2021 appellate brief, the Veteran’s representative contended that the Veteran has experienced gastrointestinal issues since active service. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of pathology and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the February 2020 VA addendum opinion. Based on the foregoing, service connection for a gastrointestinal disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); Gilbert, 1 Vet. App. at 55-57. 5. Entitlement for service connection for a bilateral eye disability The Veteran seeks service connection for a bilateral eye disability, to include cataracts. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Service treatment records reflect that in December 1978, the Veteran sought treatment for redness in both eyes. Treatment providers assessed conjunctivitis, but no abrasion was noticed. At an October 1982 report of medical history clinical exam, the Veteran reported eye trouble. Vision was noted as 20/20. In November 2012, the Veteran appeared for a routine eye exam. Relevant history indicated presbyopia, but was otherwise silent for eye issues. In July 2013, the Veteran reported a history of dry eye and allergic conjunctivitis. He reported that his eyes were blurry. At a July 2015 visit, the Veteran reported that his eyes were blurry, and requested a recheck of his prescription. The Veteran was afforded a VA examination in March 2017. The Veteran reported that his condition began in 2000, and was found by an eye exam. He reported blurry vision, dry and watery eyes. The examiner diagnosed meibomian gland dysfunction. The examiner opined that the claimed condition is less likely related to service. He explained that the Veteran no longer has cataracts. Further, upon review of the record the examiner found the only mention of cataracts was from a medical exam in March 1993. Thus, the examiner concluded that the Veteran did not have a current cataract disability. The examiner also assessed meibomian gland dysfunction, which he opined may had its onset while the Veteran was in service. The Board concludes that the service connection for cataracts is not warranted. The Veteran does not have a current diagnosis of a cataract condition and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The March 2017 VA examiner evaluated the Veteran and reviewed the medical evidence in the file. The examiner’s opinion is probative because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no competent medical opinion to the contrary. The Veteran believes his bilateral eye disability is related to an in-service injury, event, or disease, but he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of internal eye pathology and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of this Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). The VA opinion outweighs the Veteran’s lay contention regarding causal nexus. The Board finds, however, that service connection for meibomian gland dysfunction is warranted. The March 2017 VA examiner indicated that the Veteran has a current diagnosis of meibomian gland dysfunction, and he indicated that this condition was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. Although the examiner clarified in the rationale that although this condition was not caused by military service, he acknowledged that it had onset during active service. There is no competent medical opinion to the contrary. Based on the foregoing, service connection for a bilateral eye disability, specifically meibomian gland dysfunction, is warranted. 6. Entitlement to service connection for degenerative joint disease of the right knee The Veteran seeks service connection for degenerative joint disease of the right knee. The question for the Board is whether the Veteran has a right knee disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Service treatment records reflect complaints of right knee pain in 1977. An October 1982 report of medical history indicated trick or locked knee, which was described as associated with left knee ruptured anterior cruciate ligament and excision of loose body. Post-service treatment records show that in July 1991, the Veteran sought an orthopedic evaluation for right knee pain and limited range of motion. A March 1993 x-ray of the right knee revealed some degenerative changes, although not as severely as in the left knee. The provider assessed degenerative changes of the right knee. At a January 2007 VA examination, the examiner noted crepitus and pain in the last 10 degrees of extension of the right knee. In September 2008, the Veteran underwent a total right knee arthroplasty. Surgeons assessed degenerative arthritis of the right knee and a synovial popliteal cyst of the right knee. The Veteran was afforded a VA examination for the knee and lower leg in October 2014. However, the examiner did not clearly assess the right knee condition or provide a related diagnosis for the right knee. The Veteran was afforded a VA examination in March 2017. The examiner opined that the claimed condition is less likely than not related to service. However, as noted in the Board’s remand, the VA examiner’s rationale is not adequate. The VA examiner further opined that the Veteran’s right knee disability is not the result of or caused by the Veteran’s co-existing left knee joint condition. The examiner explained that arthritis in one joint is not caused by arthritis in another joint. The examiner indicated that there is insufficient documentation by which to establish cause, progression, or a baseline for aggravation of the right knee condition. The Veteran was afforded a VA examination in May 2017. The Veteran reported that he injured his left leg and knee during service. He asserted that he put all his weight on his right leg, which caused his right leg and knee to hurt. A VA examiner provided a clarifying addendum opinion in February 2020. The examiner opined the right knee condition is less likely than not incurred or caused by the claimed in-service injury, or had onset within a year of service discharge. The examiner explained that the Veteran reported right knee symptoms in 1977, which was diagnosed as a strain of the right collateral ligament. She noted that examination in April 1983 showed no pathology. She indicated that medical evidence does notate degenerative joint disease of both knees in August 1993, but that this was 10 years post military. She explained that osteoarthritis risk increases with age and obesity contributes. She concluded that there is no medical evidence supporting a right knee disorder in the military or one year post discharge that is correlated with the Veteran’s current right knee osteoarthritis resulting in a total knee arthroplasty in 2008. The Veteran has a current diagnosis of degenerative arthritis of the right knee, status post arthroplasty, as evidenced by September 2008 operative notes. Degenerative arthritis is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. However, the disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. Private treatment records show the Veteran was not diagnosed with degenerative arthritis of the right knee until 1993, years after his separation from service and years outside of the applicable presumptive period. While the Veteran is competent to report experiencing symptoms of right knee pain since service and consistently since service, the Board finds the reports of continuity of symptomatology not credible. The Veteran’s reports are internally inconsistent with his reports in contemporaneous treatment records. Service treatment records show that the Veteran consistently reported left knee pain, examination in 1983 did not reveal any right knee pathology and medical records are silent for complaints, diagnosis, or treatment related to the right knee between 1977 and 1993, outside of the presumptive period. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Further, while the Veteran asserts that the reported symptoms were manifestations of right knee arthritis, he is not competent to determine that these symptoms were manifestations of arthritis as the Veteran has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Service connection for right knee arthritis may still be granted on a direct or secondary basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s right knee arthritis and an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. The February 2020 VA addendum opinion stated that the Veteran’s right knee arthritis is not at least as likely as not related to an in-service injury, event, or disease. The examiner explained that examination in April 1983 showed no right knee pathology, and that osteoarthritis is a common form of arthritis whose risk increases with age and obesity. The March 2017 VA examiner opined that the right knee arthritis, status post knee replacement, is not the result of, caused by, or aggravated by his left knee joint condition. The March 2017 VA examiner explained that arthritis in one joint is not caused by arthritis in another joint. Further, he indicated that there is insufficient documentation to support cause, progression, or aggravation of the right knee joint. While the Veteran believes his right knee disability is related to an in-service injury, event, or disease, including secondary to his service-connected left knee disability, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Based on the foregoing, service connection for a right knee disability, claimed as cataracts, is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); Gilbert, 1 Vet. App. at 55-57. 7. Entitlement to service connection for a thoracolumbar spine disorder The Veteran seeks service connection for a low back disorder. He asserts that his back disability is related to his service-connected left knee disability. The Veteran has a current diagnosis of thoracolumbar arthritis as evidenced by the March 2017 VA examination. Osteoarthritis is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. Service treatment records reflect that the Veteran reported low back pain in February 1983, although x-ray findings were negative. Service treatment records are otherwise silent for complaints, diagnosis, or treatment of a low back condition. Post-service treatment records show the Veteran sought treatment for neck pain, which included some imaging of the thoracolumbar spine. A March 1993 x-ray indicated mild spondylosis of the lumbosacral spine, however, no compression fracture or disc space abnormalities were seen. A June 1995 x-ray of the lumbosacral spine revealed bony structures that were diffusely osteopenic. Vertebral bodies were of normal height and alignment, and the invertebral disc spaces were preserved. In March 2005, the Veteran reported that he had back pain after he pulled his left knee and low back while coughing. The Veteran was afforded a VA examination in March 2017. The Veteran reported that his back pain symptoms started between 1972 and 1977. He reported that his low back pain has gotten worse while driving, sitting and standing. The examiner diagnosed osteoarthritis of the thoracolumbar spine. The Veteran was afforded a VA examination in May 2017. The examiner opined that the claimed condition is less likely related to service. The examiner indicated that there were no back injuries or complaints cited during military service, which the Board in its remand previously explained is inconsistent with the Veteran’s report of low back pain in February 1983. The examiner also explained that the generalized nature of the current arthritis findings is most consistent with age-related changes reflective of the Veteran’s age. Further, he noted that the duties performed by the Veteran are not considered risk factors for the development of the current arthritis findings. The May 2017 VA examiner also opined that the claimed condition is less likely than not proximately due to or the result of the Veteran’s left knee disability. The examiner explained that arthritis in one joint does not cause arthritis in another joint. Further, he reiterated that the generalized nature of the current lumbar spine arthritis findings is most consistent with age-related changes. In February 2020, a VA examiner offered a clarifying addendum opinion. The examiner opined that the Veteran’s low back disability is less likely than not related to service. She explained that radiology findings document the Veteran with spondylosis of thoracic spine in July 2002. She stated that spondylosis is a term for age-related wear and tear affecting the spinal discs. She further noted that the evidence showed minimal to mild spondylosis 19 years after discharge, which validated aging as the basis for degenerative joint disease. The examiner acknowledged report of low back pain in February 1983, but noted that radiology findings of the back were normal. Further, the May 1985 report of medical history indicated that the Veteran reported no recurrent back pain. Thus, she concluded that the medical evidence does not establish a correlation or nexus between the Veteran’s low back pain in 1983 and his mild or minimal spondylosis diagnosed 19 years later. The disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. While the Veteran is competent to report experiencing symptoms of back pain since service and consistently since service, the Board finds the reports of continuity of symptomatology not credible. The Veteran’s reports are internally inconsistent with his reports in contemporaneous treatment records, which show that he persistent left knee pain and intermittent neck and abdominal pain, but no complaints or significant treatment for low back pain until decades outside of the presumptive period. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006); see also Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (explaining that where there is a lack of notation of medical condition or symptoms where such notation would normally be expected, the Board may consider this as evidence that the conditions or symptoms did not exist). Treatment notes indicate that the Veteran reported that he pulled his back after coughing in 2005. Additionally, private office visit notes reflect that the Veteran sought initial treatment for acute low back pain in July 2018, and reported onset approximately 6 days before the visit. Further, while the Veteran asserts that the reported symptoms were manifestations of thoracolumbar arthritis, he is not competent to determine that these symptoms were manifestations of arthritis as the Veteran has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board gives more probative weight to competent medical evidence, which establishes that these symptoms are instead attributable to age-related changes of the thoracolumbar spine. While the May 2017 VA examiner did not adequately consider the complaint of low back pain in 1978, his explanation that the generalized nature of the current clinical findings is consistent with age-related changes remains persuasive. Further, the February 2020 VA examiner specifically considered the in-service low back pain, but found it less likely related to current lumbar osteoarthritis. She explained that spondylosis is a term for age-related changes, and that evidence from 19 years after discharge showing mild or minimal changes validated age-related changes as the basis for the degenerative joint disease. Service connection for lumbar osteoarthritis may still be granted on a secondary basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s osteoarthritis and an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. The May 2017 VA examiner opined that the Veteran’s lumbar osteoarthritis is not at least as likely as not related to an in-service injury, event, or disease, including as secondary to his service-connected left knee disability. The examiner explained that arthritis in one joint does not cause arthritis in another joint. Further, he stated that the generalized nature of the current lumbar spine arthritis findings is most consistent with age-related changes. While the Veteran believes his low back disability is related to an in-service injury, event, or disease, including as secondary to his left knee disability, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires specialized medical education and/the ability to interpret complicated diagnostic medical testing. Consequently, the Board gives more probative weight to the competent medical evidence. Based on the foregoing, service connection for a thoracolumbar spine disability is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); Gilbert, 1 Vet. App. at 55-57. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Lauritzen, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.