Citation Nr: 21013604 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 09-35 156 DATE: March 9, 2021 ORDER Entitlement to service connection for a right knee disability is denied. FINDING OF FACT The preponderance of the evidence of record does not demonstrate that the Veteran’s right knee disability, which was best characterized as osteoarthritis, was chronic in service and manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology was not established; and the disability was not otherwise etiologically related to an in-service event, injury or disease. CONCLUSION OF LAW The criteria for service connection for a right knee disability have not been 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 FINDING AND CONCLUSION The Veteran had active service from July 1966 to July 1969 and from February 1976 to April 1976. The Veteran died in June 2018, and the appellant is his surviving spouse. The appellant has been determined to be a proper substitute as claimant with respect to the Veteran’s claim, as reflected in August 2018 correspondence. As such, the Board finds that the appellant has been substituted as the claimant with respect to the issue on appeal. See 38 U.S.C. § 5121A; 38 C.F.R. §§ 3.509(b), 3.1000(a). This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2008 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In March 2017, this case was initially before the Board. In March 2017, the Board, in pertinent part, reopened the claim for entitlement to entitlement to service connection for a right knee disability and remanded the claim on the merits for further development. Thereafter, an October 2017 Board decision denied entitlement to service connection for a right knee disability. However, the Veteran appealed the Board’s denial of the claim to the United States Court of Appeals for Veterans Claims (Court). In a May 2019 Memorandum Decision, the Court vacated the Board’s denial of the claim, and remanded the matter back to the Board for development consistent with the Memorandum Decision. Pursuant to the May 2019 Memorandum Decision, the Board remanded the claim in January 2020 and October 2020 for further development. It now returns for appellate review. In his September 2009 VA Form 9, substantive appeal, which perfected the appeal herein, the Veteran indicated he desired a hearing before a Veterans Law Judge. However, in September 2009 correspondence, the Veteran withdrew the hearing request. Thus, the Veteran’s hearing request was previously withdrawn, and the Board may proceed with appellate review. 38 C.F.R. § 20.704(e). 1. Entitlement to service connection for a right knee disability During his lifetime, the Veteran contended that service connection for a right knee disability was warranted. Specifically, in his original May 1976 application, in part, for a right knee disability, the Veteran reported he had a bilateral knee injury in April 1976. In a May 1985 statement, the Veteran also reported, in part, that he had a right knee injury in March 1976 as well as VA treatment in 1977 and 1978. In May 1990 testimony, within the context of another claim, he again reported, in part, that he hurt his knee in 1976. However, the Veteran’s May 1990 testimony may have referred to his left knee, as in a June 1990 statement, he reported in part, his left knee kept giving out on him. A March 2005 VA treatment record also documented the Veteran complained of his knees having pain from military injury. In a September 2006 statement, the Veteran reported his right knee was injured in the service on March 23, 1976. Additionally, in April 2016, the Veteran’s representative argued that the Veteran contended that he was entitled to service connection for his right knee with osteoarthritis due to injury that happened in service, and more recently, in January 2021, the appellant’s representative argued that the Veteran and his spouse stated that pain caused the Veteran functional loss since he separated from service. 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). The question for the Board is whether the Veteran had a right knee disability, to include a qualifying right knee disability, that manifested to a compensable degree in service or within the applicable presumptive period, whether continuity of symptomatology has existed since service for a qualifying disability, or whether he had a right knee disability which was otherwise shown to be etiologically related to an in-service injury, event, or disease. In this regard, the April 2017, February 2020 and October 2020 VA examiners each identified the Veteran had a diagnosis of right knee osteoarthritis, which is consistent with the other evidence of record. Accordingly, the Board will find that during the pendency of the claim, the Veteran had a right knee disability, best characterized osteoarthritis of the right knee, and as such, the issue before the Board becomes whether this disability was as a result of his active service. However, while the Veteran had osteoarthritis of the right knee, which is a chronic disease under 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a), it did not manifest to a compensable degree within the presumptive period, and continuity of symptomatology was not established. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). In this regard, the May 2019 Memorandum decision found the Board errored as it did not make a clear finding that the Veteran had not felt pain since service, and although the Board perhaps implied that it was discounting the Veteran’s statements because of what it considered contradictory evidence, it did not actually make an explicit finding that the proffered evidence was not credible. However, the Board now explicitly finds the weight of the evidence demonstrates that symptoms of the Veteran’s right knee disability were not continuous since service, and that his assertions, as proffered during his lifetime, of right knee problems during and since service, are largely not credible. The Veteran was certainly competent to describe the extent of his current symptomatology and the continuity of perceivable symptomatology from service onward, as related to his osteoarthritis of the right knee. See Layno v. Brown, 6 Vet. App. 465 (1994). However, his assertions, as proffered during his lifetime, of continuity of symptomatology are largely not credible as they were undermined by the absence of any report of symptomatology of osteoarthritis of the right knee during service or until many years after separation from service. In this regard, the Veteran’s post service medical records do not reflect chronic right knee related complaints. Specifically, an October 1976 VA examination report documented the Veteran reported he had trauma to the right knee, and that it would occasionally ache but it had no other problem. The October 1976 VA examiner endorsed a diagnosis of mild symptomatic residuals of old injury to right knee. However, notably, October 1976 VA imaging also documented as to both the Veteran’s knees, there was no bone or joint abnormalities visualized radiographically. A March 1980 VA treatment record also described, in part, that the Veteran complained of varicose veins but also stated his right knee was not a problem. During an October 1981 VA examination, the Veteran reported he injured one of his knees at VA hospital in August 1976 or 1977 and that it gave him problems but he did specify which knee was injured in August 1976 or 1977. Thereafter, a January 1985 VA treatment record documented the Veteran stated he had pain and twisting in his right knee that started that morning, and a February 1985 VA treatment record noted, in part, he had right knee chondromalacia. A May 1985 VA treatment record documented the Veteran had pain in his right knee, which onset a couple hours ago, that he felt sharp pain in the posterior of his knee while walking and denied any injury or past medical history. Additionally, May 1985 VA imaging found no significant bony, joint or soft tissue abnormality. A June 1985 VA treatment record noted the Veteran had a history of right patellar dislocation five years, and that two weeks ago, he had a complaint of right patellar pain while walking, and provided an impression of right patellar chondromalacia. Thus, as described above, the evidence of record does not demonstrate the Veteran had chronic right knee pain or related complaints since his last separation from service in 1976. The record also reflects that after the 1976 report of an occasional ache in the knee, the Veteran next reported right knee pain in January 1985, many years after his last separation from service. Further, although the June 1985 VA treatment record also noted a history of right patellar dislocation five years ago, such still provides an onset date in approximately in 1980, years after the Veteran’s last separation from service. Significantly, in March 1980 he had denied right knee problems. Moreover, the clinical evidence shows the Veteran was not diagnosed with degenerative arthritis of the right knee until many years after his last separation from service. Specifically, March 2007 VA imaging first provided an impression of mild bilateral osteoarthritis, which was over 30 years after the Veteran’s last separation from service. Additionally, as discussed above, October 1976 VA imaging found, as to the Veteran’s right knee there was no bone or joint abnormalities visualized radiographically and May 1985 VA imaging found no significant bony, joint or soft tissue abnormality. Additionally, December 2005 VA imaging provided an impression faint bilateral chondrocalcinosis but no degenerative arthritis. While not dispositive, the passage of so many years without medical complaint between 1976 and 1985 is a factor that weighs against a finding of service incurrence and continuity. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The Board’s reliance on multiple factors, only one of which is an absence of complaints or treatment during these years after service, is consistent with the statutory and regulatory requirements to consider all evidence of record, as well as applicable precedential decisions. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one factor the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). During this period, in 1980, the Board notes that the Veteran affirmatively denied right knee problems. Further, review of the Veteran’s service treatment records does not reflect documentation of a chronic right knee injury, or complaints thereof. Specifically, the Veteran’s service treatment records documented a March 1976 right knee injury resulting in cellulitis; however, there is no documentation of a residual injury, including symptomology involving the knee joint itself. In this regard, a March 23, 1976 service treatment record documented, in part, the Veteran had a complaint of an injury to right knee due to a fall on the knee in an open area. A March 24, 1976 service treatment record documented, in part, the Veteran had an infected wound of the right knee. Another March 24, 1976 service treatment record noted the Veteran hit his right knee yesterday and had swelling and redness over lateral thigh since that morning and provided, in part, an impression of cellulitis. A March 26, 1976 service treatment record noted the Veteran had hit his right knee while marching on March 23, 1976, had an infected wound right knee, and on March 25, 1976 he had debridement (infected site). A March 29, 1976 service treatment record noted the Veteran had a knee abrasion, patellar crepitus, but other findings were negative, and provided, in part, an assessment of chondromalacia. However, the Veteran’s service treatment records do not reflect continuing complaints regarding his right knee following this documented March 1976 injury. Moreover, a March 29, 1976 sick slip generally indicated the Veteran returned to duty. Thereafter, April 1976 service treatment records documented the Veteran sought mental health treatment but did not reflect any further treatment for his right knee. In this regard, Board finds that if the Veteran had experienced a chronic right knee disability or related symptoms following the March 1976 injury, it would have been reasonable for him to have continued to reported it and it would have been noted in the subsequent April 1976 service treatment records; however, as discussed, there is no record of a diagnosis of a right knee disability, or complaints thereof until 1985, other than the occasional ache reported in October 1976. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (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 condition or symptoms did not exist). Additionally, as discussed in more detail below, the October 2020 VA examiner found, in part, the likelihood that the Veteran’s right knee injury as described in his service treatment records was very unlikely to have resulted in chronic residual right knee pain and osteoarthritis. The October 2020 VA examiner explained the evidence of record did not indicate that the Veteran’s infected right knee wound was anything more than a skin infection (noted to be cellulitis on March 24, 1976) and there was no indication that the infection extended into the knee joint, specifically there was no evidence of a septic joint. The Board also recognizes the Veteran’s contentions, made during his lifetime, that his right knee injury was not an abrasion but required a cast. Specifically, in an October 2008 informal notice of disagreement, the Veteran reported he wore a cast on his right leg in military for four weeks and had to use crutches to get around and that one would not get that treatment for an abrasion. In a December 2008 statement, the Veteran reported, as to his right knee, that during service, he was in a cast for six weeks after hurting it. In his September 2009 VA Form 9, substantive appeal, the Veteran reported, in part, that as to his right knee he did have a cast on his right knee which was covered with plastic. However, in June 1976 statement, he described that during service, soon after his cast was off as to his right ankle, he fell and injured both knees and spent two days in the hospital. Consistent with the Veteran’s June 1976 statement, his service treatment records document the existence of an ankle injury prior to his March 1976 fall injuring his right knee. Further, the October 2020 VA examiner explained the Veteran’s service treatment records noted that he sustained an injury to the right knee in March 1976 after falling onto the knee and that the wound became infected and required hospitalization from March 24, 1976 to March 26, 1976 and that he was diagnosed with cellulitis and an infected wound of the right knee. However, as discussed above, the Veteran’s service treatment records do not reflect his March 1976 right knee injury required a cast for a period of several weeks. Further, during his lifetime, the Veteran provided inconsistent statements asserting that his right knee disability had onset during his active service and continued thereafter which reduces the credibility of these statements regarding continuity. Specifically, as discussed above, the Veteran had generally argued, and now the appellant generally argues, that the Veteran injured his right knee during service in March 1976, and that his symptoms continued thereafter. However, conversely, as discussed above, in October 1976 he reported an occasional ache, but no other problems and in a 1980 treatment record the Veteran denied right knee problems. In a January 1985 VA treatment record, the Veteran stated he had pain and twisting in his right knee that started that morning, and a May 1985 VA treatment record documented the Veteran reported pain in his right knee, which onset a couple hours ago, and that he denied any injury or past medical history. Also a June 1985 VA treatment record noted the Veteran had a history of right patellar dislocation five years. Thus, the 1985 record does not reflect the Veteran reported his right knee disability onset during service in March 1976 but rather reflect his knee pain onset post service. Also, during an October 1981 VA examination, the Veteran reported he injured one of his knees at VA hospital in August 1976 or 1977 and that it gave him problems. Thus, although he did not specify which knee he was referring to as being injured post service, he also did not report a right knee injury which had continued since service, including since March 1976. Additionally, an October 2005 VA treatment record documented as to the Veteran’s military history he had left knee and lower back injuries but did not reference a right knee injury. Thus, this evidence also weighs against the claim. The May 2019 Memorandum decision noted the appellant argued her husband generally treated himself with Tylenol, and thus presumably would not have sought frequent treatment. Accordingly, the May 2019 Memorandum decision directed the Board explain why it would expect someone who treated knee pain with Tylenol to have frequent doctor visits. In this regard, the Veteran’s post service medical records, dated between his separation from service in 1967 include the report of an occasional ache in October 1976, and his complaint regarding his right knee in 1985, reflect numerous other complaints, including musculoskeletal complaints, but do not reflect any other right knee complaints. In fact, in March 1980 it was noted that the right knee was “not a problem.” Specifically, a May 1982 VA treatment record documented, in part, the Veteran presented with a three to four week history of pain in the left lower extremity and that pain occurred after 15 minutes of walking, and was described as sharp, constant pain. A May 1983 VA treatment record documented the Veteran reported low back pain since 1974 pain, which radiated into his left leg. A January 1984 VA treatment documented the Veteran had chronic low back pain, a February 1984 VA treatment record documented he had left knee pain and stiffness, and a June 1984 VA treatment noted he requested a back brace. An August 1984 VA treatment record documented the Veteran had epigastric pain. In this regard, the Board finds that if the Veteran had experienced a chronic right knee disability, it would have been reasonable for him to have reported it in these post service medical records, even if he was using Tylenol, as he reported other complaints. Further, the Veteran’s VA treatment records, beginning after his complaint of right knee pain in 1985, do, in fact, reflect the use of over the counter medication, including Tylenol. However, the first indication of the Veteran’s use of Tylenol specifically for his right knee disability was in July 2000. Specifically, a July 2000 VA treatment record documented, as to the Veteran’s right knee, he stated that Tylenol gave minimal relief. The Board recognizes the Veteran’s report in July 2000 that Tylenol gave minimal relief, is contrary to his report, in a February 2016 VA treatment record, that he was satisfied with Tylenol as to his pain in his right knee and back pain. Nonetheless, the Veteran’s July 2000 report that Tylenol gave minimal relief as to his right knee would presumably have resulted in him seeking prior right knee treatment as minimal relief is not the equivalent of satisfactory treatment. Moreover, rather than indicating that the Veteran self-treated himself with over the counter medication, including Tylenol, some records, in fact, reflected the Veteran was directed by medical providers to use Tylenol for his pain. Specifically, a January 2016 VA treatment record documented to have the Veteran increase the dose of Tylenol, up to 2 tabs (maximum 3 grams a day) and that this would be discussed further with him at the next visit. A February 2016 VA treatment record documented as to the Veteran’s osteoarthritis in the neck and knee, an increase of Tylenol 500mg to 2 tabs three times a day as needed. A March 2016 VA treatment record noted as to the Veteran’s medications he used for pain, he used Tylenol, 1 tab three times a day, if needed, and a December 2016 VA treatment record documented, the Veteran agreed take Tylenol for generalized aching. Also, February 2017 and March 2017 VA treatment records noted as the Veteran’s medications used for pain, he used Tylenol 500 mg pro re nata (PRN). Similarly, September 2015, June 2016, November 2016, February 2017 and April 2017 VA treatment records noted as to the Veteran’s osteoarthritis in the neck and knee, to continue use of Tylenol. Additionally, the record prior to the Veteran’s July 2000 use of Tylenol for his right knee also reflects he utilized Tylenol for other disabilities. Specifically, a July 1998 VA treatment record documented the Veteran reported achy joints in his left hand relieved with Tylenol. A November 1999 VA treatment record documented as to the Veteran’s back pain he received ibuprofen and Tylenol PNR. A February 2000 VA treatment record documented as to the Veteran’s left knee he was taking Tylenol with little to no effect. Further, records subsequent to July 2000 also reflect the Veteran used Tylenol for his left ankle in March 2004, inflamed and probably infected gums and possible maxillary sinus inflammation or infection in June 2004, left hand/forearm pain in November 2004, muscle aches since EMG testing in December 2004, sinus congestion, sinus drainage and pain over the maxillary sinuses in May 2005 and bilateral hip pain in August 2005. More recently, an April 2015 VA treatment record documented the Veteran used occasional Tylenol for headache and a January 2016 VA treatment record reflected, in the context of back pain, he used Tylenol only as needed. Further, the evidence is also conflicting as to whether the Veteran consistently used over the counter medications, including Tylenol, for his right knee pain. In this regard, VA treatment records, dated in January 2016 and February 2016 noted the Veteran had pain in his back and right knee and that he was not taking any oral agents for pain. A May 2007 VA treatment record also documented the Veteran stated that he had chronic knee pain and back pain and stated that he did not like to take medications, that he was going to physical therapy and was thinking about cortisone shots. Conversely, other VA treatment records, including dated in March 2006, noted the Veteran was prescribed tramadol for low back and knee pain. Thus, the evidence does not demonstrate the Veteran consistently used over the counter medications as to his right knee disability. Moreover, the appellant, in her June 2018 VA Form 21P-534EZ, Application for DIC, Death Pension, and/or Accrued Benefits, reported that she married the Veteran in December 2016. There is nothing in the record to establish a particular date prior to December 2016, for the appellant to have a basis for any knowledge as to when, or if, the Veteran may have taken Tylenol for his right knee pain. There are also no statements of record from the Veteran which reflect, as to his right knee, he self-medicated with Tylenol since 1976. Thus, in weighing the evidence, the Board finds the Veteran’s service treatment records and post service medical records, are more probative than the Veteran’s contentions, during his lifetime, and the appellant’s current contentions, that the Veteran’s right knee disability onset during service, and continued thereafter, to include self-treatment with Tylenol, made many years after service for compensation purposes. See Curry v. Brown, 7 Vet 59 (1994); Cartwright v. Derwinski, 2 Vet. App. 24, 25-26 (1991) (a pecuniary interest may affect the credibility of a claimant’s lay testimony); see also Caluza v. Brown, 7 Vet. App. 498 (1995) (giving factors to consider when assessing the credibility of lay evidence, to include facial plausibility, internal consistency, consistency with other evidence, self-interest or bias, bad character, malingering, or lay statements made during treatment). Thus, to the extent the Veteran contended, or the appellant contends, that the Veteran had chronic symptoms of a right knee disability in service, or shortly after service, and ever since, the medical and lay evidence of record does not support this contention. For these reasons, the criteria for presumptive service connection based on chronic symptoms in service, continuous symptoms since service, or that osteoarthritis of the right knee manifested to a compensable degree within one year of service separation, have not been met. Service connection for a right knee disability, best characterized as osteoarthritis, may still be granted on a non-presumptive direct-incurrence basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s right knee disability and an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d). In this regard, the January 2020 Board decision found the prior April 2017 VA examiner’s opinion inadequate and remanded the claim for another opinion. In October 2020, the Board found the resulting February 2020 VA examiner’s opinion inadequate and remanded for another opinion. Accordingly, the Board will not address these prior opinions but will address the most recent October 2020 VA opinion. The October 2020 VA examiner found it was less likely as not that the Veteran had a chronic right knee disability that was causally or etiologically related to service. The October 2020 VA examiner explained the Veteran’s service treatment records noted that he sustained an injury to the right knee in March 1976 after falling onto the knee and that the wound became infected and required hospitalization from March 24, 1976 to March 26, 1976 and that he was diagnosed with cellulitis and an infected wound of the right knee. However, the October 2020 VA examiner also explained the Veteran had an October 1976 VA examination, which noted that he had trauma to the right knee and that it occasionally ached him but that he had no other problems with the knee. The October 2020 VA examiner explained the October 1976 VA examiner noted a normal examination of the right knee, gave a diagnosis of mild symptomatic residual of old injury to right knee, that knee x-ray was normal at this time and that there was no mention of any sign that the infected wound noted a few months prior had persisted. The October 2020 VA examiner noted the Veteran, during his lifetime, and his wife, purportedly claimed that the Veteran had continuity of symptomatology and treatment for a right knee disability since separation, to include treatment with over the counter medication. However, the October 2020 VA examiner explained the Veteran’s right knee condition at the time of his death was right knee osteoarthritis, which was diagnosed first in March 2007, and that he had an x-ray of the right knee in October 1976 which normal with no bone/joint abnormalities, and therefore no osteoarthritis. The October 2020 VA examiner also explained that imaging of the Veteran’s right knee was again normal in May 1985 and December 2005 and osteoarthritis was not noted on right knee imaging until March 2007. The October 2020 VA examiner also stated she could not provide a nexus to connect the Veteran’s purported complaints of right knee pain necessitating over the counter medication since separation to his diagnosed right knee condition at the time of his death (right knee osteoarthritis) as he had a normal radiologic examination of the right knee on at least three separate occasions after separation in 1976, and did not develop osteoarthritis in his right knee until March 2007, over 30 years after separation. The October 2020 VA examiner also explained the Veteran’s service treatment records supported that he suffered an acute, transitory right knee injury/abrasion during service in 1976 but in no way did this support the development of osteoarthritis in the right knee 30 years later. The October 2020 VA examiner also explained the Veteran’s right knee injury, as described in his service treatment records, indicated that he had an infected right knee wound but did not indicate that this was anything more than a skin infection (noted to be cellulitis) and there was no indication that the infection extended into the knee joint - no evidence of a septic joint. The October 2020 VA examiner further explained the Veteran had symmetrical bilateral knee osteoarthritis, which was not consistent with post-traumatic arthritis from any remote in-service right knee injury, and it was unlikely that the Veteran’s remote right knee injury in service caused his right knee osteoarthritis three decades later. The October 2020 VA examiner explained the currently available evidence of record noted that the Veteran twisted his right knee in 1985 and was felt to have a possible meniscus injury, that another clinic note shortly after noted a history of a right patellar dislocation five years ago (so approximately 1980) and a diagnosis of patellar chondromalacia, and it appeared that the Veteran suffered a right knee injury in approximately 1980 following separation, which was unrelated to his right knee skin infection/cellulitis during service four years prior. Thus, the October 2020 VA examiner explained while the Veteran, and now his wife, could report that he had right knee pain and took over the counter medications, one could not delineate what the cause was for his right knee pain that necessitated over the counter medications – if it was an acute right knee skin infection/cellulitis in 1976, or a dislocated patella in 1980, or possible meniscus injury in 1985. The October 2020 VA examiner stated that simply stating that one had right knee pain since separation and took over the counter medications should not be a reason to overlook the documented right knee injuries that occurred after separation that were most likely the cause of this Veteran’s chronic right knee pain. Thus, as discussed, the October 2020 examiner explained the reasons for her conclusions based on an accurate medical history and provided explanations that contained clear conclusions and supporting data, with consideration of the Veteran’s subjective complaints, as proffered during his lifetime, as well the appellant’s assertion that the Veteran utilized over the counter medication. Thus, the October 2020 VA examiner’s opinion is entitled to substantial probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In an October 2009 statement, the Veteran reported, as to his right knee, a VA doctor told him that his knee disability could be caused from a driving force with the Guard in 1976. However, the Veteran did not explain as to if he was reporting a contemporaneous account of what a doctor purportedly said, and a layman’s account filtered as it was through a layman’s sensibilities, is simply too attenuated and inherently unreliable to hold any probative value as the etiology of the Veteran’s right knee disability. Robinette v. Brown, 8 Vet. App. 69 (1995). Further, there is no indication that the VA doctor the Veteran referred to reviewed any service treatment records nor was any rationale relayed by the Veteran. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). While the Veteran believed, and the appellant believes, that the Veteran’s right knee disability was related to his service, they have not been shown to have the requisite medical knowledge and expertise to be deemed competent to provide a nexus opinion in this case. This issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence, specifically the October 2020 VA examiner’s opinion, which was rendered by a medical professional in contemplation of the complete claims file and in consideration of known medical principles and available medical literature.   Thus, based on the reasons and bases discussed, the preponderance of the evidence is against the claim, and the benefit of the doubt rule is inapplicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, service connection is not warranted for a right knee disability. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Espinoza 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.