Citation Nr: 21028528 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-03 642 DATE: May 11, 2021 ORDER Service connection for a right knee disability is denied. Service connection for a low back disability is denied. Service connection for a right hip disability is denied. FINDINGS OF FACT 1. The Veteran's right knee disability did not have its onset during active service and is not otherwise related to active service. 2. The Veteran's low back disability did not have its onset during active service and is not otherwise related to active service. 3. The Veteran's right hip disability did not have its onset during active service and is not otherwise related to active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a low back disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for a right hip disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1967 to April 1971. The case is on appeal from a May 2014 rating decision. In September 2018 and July 2020, the Board remanded the claims on appeal for additional development. Service Connection Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. Certain chronic diseases, including arthritis, will be presumed related to service if they were shown as chronic in service (or within a presumptive period) and there are subsequent manifestations of the same chronic diseases; or if they manifested to a compensable degree within a presumptive period following separation from service (in this case, one year); or if they were noted in service, with continuity of symptomatology since service. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.303, 3.307, 3.309. 1. Service connection for a right knee disability. Evidence The Veteran's service treatment records (STRs) included various notes relevant to the right knee disability claim. The Veteran's March 1967 enlistment examination report noted upon clinical evaluation that the lower extremities were normal, noted no relevant defects or diagnoses and noted that the Veteran was qualified for enlistment. A May 11, 1967 STR noted that a May 6, 1967 x-ray of both knees was unremarkable. A May 25, 1967 STR noted that a May 11, 1967 x-ray of both knees was unremarkable. A May 15, 1967 STR consultation sheet stated that the Veteran "complains of painful knees of approx[imately] 4 y[ea]rs duration...also states knees now are worse than ever. He doesn't localize pain, and states it is there all the time." X-rays were noted as negative and an impression was noted of "[k]nee pain etio[logy]?" A May 18, 1967 STR consultation sheet noted a provisional diagnosis of "[b]ilateral knee pain ? etiology" and noted eight physical therapy treatments. A June 14, 1967 STR consultation report stated "X-rays reviewed still neg[ative]," that "[e]xam of knees unchanged" and noted an impression of "I can still find no objective evidence of intraarticular pathology." An April 1970 STR consultation sheet stated that the Veteran "has long [history] of locking in [right] knee." This appears to have been a mistaken reference to the left knee, as other portions of the STR referenced the left knee, to include a statement of "[p]ainful [left] knee [with] crepitus and locking" and a disposition of "arthrogram of left knee." A June 1970 narrative summary STR noted that the Veteran was admitted on May 11, 1970 and discharged from the Naval Hospital in Long Beach to a medical holding company following a left medial meniscectomy. It was also stated that the Veteran "had one episode where his right knee swelled up on him." No diagnosis was noted related to the right knee. An August 1970 STR primarily address the post-operative left knee, but also stated "will follow [right] knee." A September 1970 record from the Naval Hospital in Long Beach, submitted by the Veteran in November 2012, noted the Veteran's discharge from a medical holding company and stated that the Veteran "was examined this date and found fit for return to full duty." The Veteran's April 1971 separation examination report noted upon clinical evaluation that the lower extremities were normal, noted no relevant defects or diagnoses and noted that the Veteran was qualified for release from active duty. Also of record is a VA Form 21-526e (Veteran's Application for Compensation or Pension at Separation from Service) signed by the Veteran on May 25, 1970. The Veteran noted a right knee injury, listed May 11, 1970 as the date such began and noted treatment for the right knee injury on May 11, 1970 at the Naval Hospital in Long Beach. Additionally of record is a VA Form 21-526e signed by the Veteran on April 12, 1971 (the date of his discharge from active service). The Veteran noted "operation proposed for [right] knee," listed "67 June?" as the date such began and noted treatment at the Long Beach Naval Hospital from April to May 1970 and stated "right knee found." Other lay statements of record from the Veteran raised the issue of secondary service connection between the Veteran's claimed right knee disability and his service-connected left knee disability (characterized as degenerative joint disease (DJD) left knee, status post meniscectomy). In this regard, on his June 2014 notice of disagreement (NOD), he stated "Right Knee, secondary to Left Knee." In a September 2020 statement, the Veteran stated that "[t]he inability to use my left knee (leg) properly has over the years has from over compensation has caused over wear and destruction of my right knee." He further stated that "I feel that my whole problems were caused by the injury to my left leg. This is also the conten[t]ion voiced by my doctors at the VA hosp[ital]." The Veteran was afforded multiple VA examinations and multiple VA opinions were obtained relevant to this claim. The Veteran was afforded a VA examination in October 2013 and a Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ) was completed. A diagnosis was noted of DJD of the right knee. The DBQ referenced September 2013 right knee x-ray results. Under the medical history section, it was noted that "[r]ight knee pain 'started 3-4 years ago.' He denies having had prior...injury to his right knee." The examiner provided a positive direct service connection nexus opinion for the Veteran's left knee disability and within the accompanying rationale also provided an opinion that "STRs were silent for right knee condition and no evidence is available to establish nexus for right knee service connection." The Veteran was also afforded a VA examination in October 2015 and a Knee and Lower Leg Conditions DBQ was completed by physician assistant (PA) J.J. A diagnosis was noted of right knee degenerative arthritis, with a date of diagnosis noted of 2013. Under the medical history section, it was noted that the "Veteran states he began having right knee [approximately] 20 years ago. He states he believes this is from favoring his left knee." PA J.J. also provided an opinion that "[t]he condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition." The accompanying rationale stated: Reference to the NIH site on [DJD], and a current search of PubMed shows the following risk factors: aging, genetics, overweight, previous fractures or injuries to the specific joint, and repetitive activities to the damaged joint such as squatting or twisting. Review of the literature, including NIH, does not support [DJD] (arthritis) specifically causing [DJD], in another joint, neither directly, nor due to favoring the unafflicted joint because of pain in the injured joint. It is therefore less likely that the Veteran's DJD right knee...is proximately due to or the result of his DJD left knee [status post] meniscectomy. A VA opinion was provided in November 2015 from Dr. G.M. The opinion discussed the Veteran's STRs, to include that "the [V]eteran was documented to have a complaint of bilateral knee pain and reported one episode of right knee swelling while on active duty" and that "[t]here is no documentation in the STRs of a right knee injury. There was no established right knee condition during active duty nor was there a right knee condition diagnosed soon after discharge from active duty." Post-service medical records were also discussed. An opinion was provided that "[n]o nexus for direct service connected right knee condition exists. There is no nexus of injury while on active duty and there is no right knee medical condition which was shown to persist after release from active duty" and that "[t]he [V]eteran's right knee osteoarthritis is less likely than not (less than 50% probability) had it[]s onset in service manifested by complaints of pain and swelling." The Veteran was also afforded a VA examination in August 2019 and a Knee and Lower Leg Conditions DBQ was completed by Dr. B.D. A diagnosis was noted of right knee joint osteoarthritis. Under the medical history section, it was noted that the Veteran "developed right knee pain 20 years ago. He had a RIGHT knee arthroscopy for treatment of a meniscus tear in the late 1990's or early 2000's. He [had] another right knee arthroscopy sometime after the first, but cannot recall the year." Dr. B.D. provided an opinion that "the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness." The accompanying rationale stated: The [STRs] provided document acute treatment only for transient right knee pain with normal x-rays (Illegible. Ortho consult 5/18/67). There is no evidence of chronicity of care to suggest an in-service right knee injury or condition that would result in or predispose to development of the diagnosed right knee osteoarthritis (Fowles. Report of Med Exam 9 Apr 71). Records do not document any in-service injury or condition likely to result in or predispose to development of right knee pathology or the diagnosed right knee osteoarthritis. Furt[he]r, the claimant had internal injury to the right knee with arthroscopy long after he left military service. It is well established that internal knee injury predisposes to development of knee osteoarthritis. Lastly, the claimant has a long history of obesity and excessive obesity, a condition also well documented to result in knee osteoarthritis. Dr. B.D. also provided an opinion that "[t]he claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected condition." The accompanying rationale, with citations to medical literature omitted, stated: There is no support in the medical literature for arthritis in one joint causing arthritis in another joint. The most common risk factors for osteoarthritis are advanced age, family history of osteoarthritis, being overweight, injury to the joint, history of inflammatory joint disease, metabolic or hormonal disorders, such as hemochromatosis and acromegaly, congenital joint anomalies, repetitive stressful joint use, and crystal deposits in joints...According to a relevant, published discussion paper titled "Symptoms in the Opposite or Uninjured Leg," prepared by Orthopedic Surgeons...: "There is no clear evidence to suggest that an injury to one lower extremity would have any significant impact on the opposite uninjured limb unless the injury resulted in major muscle or nerve damage causing partial or complete paralysis of the damaged leg, and/or shortening of the injured lower extremity resulting in a limb length discrepancy of more than four or five centimet[er]s so that the individual's gait pattern has been altered to the extent that clinically there is an obvious lurching type gait (a significant limp). In order for this type of gait to have impact on the opposite or uninjured leg, it is likely that the abnormal gait or limp would need to be present over an extended period of time - years. A temporary abnormality in gait, e.g. a limp over a relatively short period of time of weeks or months is unlikely to have any effect on the opposite leg. The use of a cast, cane, and crutches is also unlikely to have any major impact on the stress borne by the uninjured limb. Increased body weight (obesity) does, however, have a detrimental effect on both lower extremities and magnifies all of the previously described risk factors." In reviewing other such cases an academic orthopedic specialist noted that "There is no scientific literature to support the supposition commonly held that joints contralateral to injured joints undergo degenerative change,"...In this case the [V]eteran has evidence of prior right knee injury resulting in arthroscopic surgery and obesity, both well established causes of knee osteoarthritis and more likely to have caused the right knee arthritis in his case. Being overweight is particularly associated with development of osteoarthritis...For the knees every pound of excess weight exerts about 4 pounds of extra pressure on the knees. So a person who is 10 pounds overweight has 40 pounds of extra pressure on his knees. Dr. B.D. also provided an opinion attempting to address secondary service connection aggravation. The opinion appeared to indicate that the Veteran's right knee disability had not been aggravated. In this regard, the examiner marked a checkbox indicating that they could "determine a baseline level of severity of (claimed condition/diagnosis)...prior to aggravation or the earliest medical evidence following aggravation" and also marked a checkbox indicating that the current severity of the claimed condition/diagnosis was not greater than the baseline. The examiner further stated that "[t]he claimant reported moderate right knee pain at baseline and continues to have moderate right knee pain." In February 2021, Dr. D.C. provided an opinion stating that the Veteran's claimed condition/diagnosis was not at least as likely as not aggravated beyond its natural progression." The accompanying rationale stated: Claimant is claiming that his [left] knee is aggravating his [right] knee, [right] hip, and low back. Having one primary musculoskeletal issue causing another is largely based on anecdotal and circumstantial reasoning. Usually the claim is that it throws off gait, or "favoring" thereby causing other musculoskeletal issues, which are otherwise pathophysiologically independent of one another. The issue with circumstantial reasoning is that leads to the precedence that any 2 conditions can be linked, even though medically they are independent of one another...I cannot overlook however how many years have occurred since the initial incident with his [left] knee in 1970 until when right knee conditions started being noted in records of 40+ years, on top of his morbid obesity. Degenerative arthritis is chronic "wear and tear". Being 60+ years old and obese, the degenerative arthritis is expected to be naturally occurring. When looking at imaging, Xray of hip [bilateral] 8/17/16 noted mild degenerative changes of hips. Xray of hip [bilateral] 2019 showed mild to moderate symmetrical [DJD] (the radiologist commented symmetrical specifically). These xrays of the hips show a progression of his [DJD] from 2016 and 2019 that is equal and symmetrical. This is strong objective evidence of any favoring on one side or any significant chronic gait disturbance due to his [service-connected left] knee, but rather the [DJD] found in his back, [right] hip and [right] knee comes about because of natural wear and tear. The xray of [bilateral] knee 8/17/16 showing severe degenerative changes of [right] knee with radiologist commenting "although less severe than Left" which makes sense that there was more degenerative arthritis in [left] knee due to the [service connected] injury. Less likely than not right knee disability is aggravated beyond natural progression by [service connected left] knee. Additionally of record are extensive VA and private medical records. In general, while such records variously noted pain and reflected treatment for the Veteran's right knee, they did not provide either a nexus between the Veteran's current right knee disability and his active service or state that his current right knee disability was caused or aggravated by his service-connected left knee disability. Specific relevant records included a private November 2004 record from Dr. T.E., which referenced a September 2004 motorcycle accident and stated that the Veteran "has had complaints of...some mild...knee pain." A private January 2005 record from Family Care of Black Mountain noted a complaint of knee pain and stated that "[t]he onset of the pain has been gradual and has been occurring in an intermittent pattern for years. The course has been recurrent." A September 2012 VA primary care note was for the Veteran's initial visit and noted an impression of osteoarthritis of the knees. Analysis Direct Service Connection With respect to the first element of direct service connection, various evidence, to include the VA examinations discussed above, noted a current right knee disability. As such, the first element has been met. With respect to the second element of direct service connection, the Veteran's STRs, as discussed above, reflected treatment for the right knee. As such, the second element has been met. With respect to the third and final element of direct service connection, the key issue is whether there is a nexus between the Veteran's current right knee disability and service. The Board finds that competent evidence did not show such a nexus. See 38 C.F.R. § 3.159(a)(1) ("Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions"). In this regard, as discussed above, of record are multiple VA opinions. The Board affords no probative value to the negative October 2013 VA opinion, as it was based, at least in part, on an inaccurate factual premise that "STRs were silent for right knee condition," which as outlined in detail above, was contradicted by multiple STRs. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) ("An opinion based upon an inaccurate factual premise has no probative value"). The Board, however, finds the November 2015 VA opinion from Dr. G.M. and the August 2019 VA opinion from Dr. B.D. to be the most probative evidence of record as to the issue of direct service connection nexus. These two negative opinions were provided by doctors following examination of the Veteran and/or review of relevant records and included rationales in support of the conclusions provided that, essentially, a right knee disability was not related to the Veteran's active service. The Board notes that there is not competent evidence contrary to the conclusions provided by these negative opinions. The Board also finds probative the October 2015, August 2019 and February 2021 VA opinions addressing secondary service connection that variously referenced risk factors for the Veteran's right knee disability that were not directly related to his active service, to include "prior right knee injury resulting in arthroscopic surgery," obesity and age. To the extent that the Veteran has contended that he has a right knee disability that is related to his active service, he is not competent to provide an opinion as to the etiology of his right knee disability, as this is a complex medical issue that would require education, training or experience to address. See 38 C.F.R. § 3.159(a)(1), (2); see generally Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As to this issue, the Board affords significantly more probative value to the November 2015 and August 2019 VA opinions that, as discussed above, indicated that, essentially, the Veteran's right knee disability is not related to his active service. Overall, the Board finds that competent evidence did not indicate a nexus between the Veteran's current right knee disability and his active service. As the third element of direct service connection was accordingly not met, the Board finds that service connection on a direct basis is not warranted. Analysis Secondary Service Connection The key issue for secondary service connection is whether the Veteran's right knee disability was caused or aggravated by his service-connected left knee disability. The Board finds that this was not shown by the most probative evidence of record. In this regard, as discussed above, of record are multiple VA opinions. The Board finds the October 2015 VA opinion from PA J.J. (addressing secondary service connection causation), the August 2019 VA opinion from Dr. B.D. (addressing secondary service connection causation) and the February 2021 VA opinion from Dr. D.C. (addressing secondary service connection aggravation) to be the most probative evidence of record as to the issue of secondary service connection. These three negative opinions were provided by medical professionals following examination of the Veteran and/or review of relevant records and included rationales in support of the conclusions provided that, essentially, a right knee disability was not secondary to the Veteran's service-connected left knee disability. The Board notes that there is not any clearly articulated competent evidence contrary to the conclusions provided by these negative opinions. With respect to the October 2015 VA opinion, the Board acknowledges the Veteran's contention from his January 2016 VA Form 9 that "the medical opinion...does not, in fact, consider my individual circumstances...his opinion is not at all dependent on the facts of my case" and that "[r]ather he believes that the literature shows that [DJD] in any joint can never cause a secondary disability in another joint. I request that you have my claim reviewed by an Orthopedic specialist who can offer an opinion that takes into account the facts of my claim." As outlined, subsequent VA opinions were obtained in August 2019 and February 2021 from doctors and these opinions more clearly considered the individual circumstances of the Veteran. In contrast to the October 2015 VA opinion, the Veteran has not provided any contentions with respect to the August 2019 and February 2021 VA opinions. The Board notes that the discussion in this paragraph is equally applicable to the low back and right hip disability claims addressed below and such will not be repeated in those sections. Also with respect to the October 2015 VA opinion, the Board acknowledges that the September 2018 Board remand noted the October 2015 VA examination to be "inadequate for adjudication purposes." The Board now observes that the September 2018 Board remand only noted as an inadequacy in the October 2015 VA examination that "the examiner did not address whether the Veteran's back, right hip, and right knee disabilities are aggravated by his service-connected left knee disability." In other words, the Board did not identify any inadequacy with the secondary service connection causation opinion provided, but rather found inadequacy with the secondary service connection aggravation opinion that was not provided. As such, the Board affords the provided October 2015 VA opinion addressing secondary service connection causation probative value. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("[E]ven if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight...if the opinion is merely lacking in detail, then it may be given some weight based upon the amount of information and analysis it contains"). The Board notes that the discussion in this paragraph is equally applicable to the low back and right hip disability claims addressed below and such will not be repeated in those sections. With respect to the August 2019 VA opinion that attempted to address secondary service connection aggravation, the Board notes that in a July 2020 remand, the Board stated regarding the August 2019 opinion that "the examiner did not provide an express opinion as to whether the claimed disabilities were aggravated by the service-connected left knee disability." In effect, the August 2019 Board found the August 2019 opinion as to secondary service connection aggravation to be inadequate. As such, the Board affords no probative value to August 2019 attempted secondary service connection aggravation opinion. The Board notes that the discussion in this paragraph is equally applicable to the low back and right hip disability claims addressed below and such will not be repeated in those sections. The Board has considered the Veteran's contention that, essentially, his right knee disability is secondary to his service-connected left knee disability. The Veteran, however, is not competent to provide an opinion as to this issue, as this is a complex medical issue that would require education, training or experience to address. See 38 C.F.R. § 3.159(a)(1), (2); see generally Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As to this issue, the Board affords significantly more probative value to the October 2015, August 2019 and February 2021 VA opinions that, as discussed above, indicated that, essentially, the Veteran's right knee disability was not secondary to his service-connected left knee disability. The Board has also considered the Veteran's July 2020 statement that, essentially, his VA doctors told him that his right knee disability was secondary to his service-connected left knee disability. While VA treatment records do not appear to document such opinion, the Veteran is competent to report what he was told by his VA doctors. As such, the Board has considered the Veteran's report of what he was told by his VA doctors. The Board, however, affords limited probative value to such evidence, as there was no rationale provided in support of the reported opinion. By contrast, the Board affords significantly more probative value to the October 2015, August 2019 and February 2021 VA opinions, which, as discussed above, contained fully articulated rationales to support the conclusions provided. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("It is the factually accurate, fully articulated, sound reasoning for the conclusion...that contributes probative value to a medical opinion"). Overall, the Board finds that the most probative evidence did not indicate that the Veteran's right knee disability was caused or aggravated by his service-connected left knee disability. As such, the Board finds that service connection on a secondary basis is not warranted. Analysis Chronic Disease Presumption The Board finds that the evidence did not indicate that arthritis of the right knee was shown as chronic in service, that such disability manifested to a compensable degree within the presumptive period of one year or that such disability was noted in service with continuity of symptomatology. As such, the Board finds that service connection based on the presumption regarding chronic diseases is not warranted. Conclusion In sum, the Board finds that the Veteran's right knee disability did not have its onset during active service and is not otherwise related to active service. Overall, the Board finds that the preponderance of the evidence is against the claim and that the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is not warranted for a right knee disability. 2. Service connection for a low back disability. Evidence The Veteran's STRs did not contain any treatment or complaints related to the low back. The Veteran's April 1971 separation examination report noted upon clinical evaluation that the spine was normal, noted no relevant defects or diagnoses and noted that the Veteran was qualified for release from active duty. Relevant lay statements from the Veteran raised the issue of secondary service connection between the Veteran's claimed low back disability and his service-connected left knee disability. In this regard, on his June 2014 NOD, he stated "Lower Back, secondary to Left Knee." In a September 2020 statement, the Veteran stated that "[t]he inability to use my left knee (leg) properly has over the years has from over compensation has caused over wear and destruction of my right knee" and that "I have been told by VA doctors that this problem has also affected my back." He further stated that "I feel that my whole problems were caused by the injury to my left leg. This is also the conten[t]ion voiced by my doctors at the VA hosp[ital]." The Veteran was afforded multiple VA examinations and multiple VA opinions were obtained relevant to this claim. The Veteran was afforded a VA examination in October 2015 and a Back (Thoracolumbar Spine) Conditions DBQ was completed by PA J.J. A diagnosis was noted of degenerative arthritis of the spine, with a date of diagnosis noted of 1973. Under the medical history section, it was noted that the "Veteran states he initially injured his back when he injured his left knee in [approximately] 1968. He states he reinjured it working as a civilian in 1973 and had surgery (reports laminectomy) the same year. He states he has had chronic back pain for many years." PA J.J. also provided an opinion that "[t]he condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition." The accompanying rationale stated: Reference to the NIH site on [DJD], and a current search of PubMed shows the following risk factors: aging, genetics, overweight, previous fractures or injuries to the specific joint, and repetitive activities to the damaged joint such as squatting or twisting. Review of the literature, including NIH, does not support [DJD] (arthritis) specifically causing [DJD], in another joint, neither directly, nor due to favoring the unafflicted joint because of pain in the injured joint. It is therefore less likely that the Veteran's...DJD lumbar spine...is proximately due to or the result of his DJD left knee [status post] meniscectomy. The Veteran was also afforded a VA examination in August 2019 and a Back (Thoracolumbar Spine) Conditions DBQ was completed by Dr. B.D. A diagnosis was noted of degenerative disc and joint disease lumbar spine with spondylolysis post fusion. Under the medical history section, it was noted that the "Veteran states he initially injured his back when he injured his left knee in [approximately] 1968. [STRs] do not document a back injury or condition. He states he re-injured his back working as a civilian in 1973 and had a lumbar laminectomy the same year." Dr. B.D. provided an opinion that "the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness." The accompanying rationale stated that: [STRs] do not document an in-service injury or condition likely to result in or predispose to development of back or spinal pathology or the diagnosed degenerative disc and joint disease lumbar spine with spondylolysis post fusion (Fowles. Report of Med Exam 9 Apr 71, Pollard. Long Beach Naval Hospital Narrative Summary 4 Jun 70). Dr. B.D. also provided an opinion that "[t]he claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected condition." The accompanying rationale, with citations to medical literature and medical records omitted, stated: There is no support in the medical literature for arthritis in a joint causing degenerative spinal changes. The most common risk factors for degenerative spinal conditions are advanced age, being overweight, injury to the spine, congenital spinal disorders such as pars defects, and family history...In this case the aging [V]eteran has pars defects and obesity, both well established causes of spinal degenerative changes and more likely the cause of the spinal degenerative arthritis in his case. Dr. B.D. also provided an opinion attempting to address secondary service connection aggravation. The opinion appeared to indicate that the Veteran's low back disability had not been aggravated. In this regard, the examiner marked a checkbox indicating that they could "determine a baseline level of severity of (claimed condition/diagnosis)...prior to aggravation or the earliest medical evidence following aggravation" and also marked a checkbox indicating that the current severity of the claimed condition/diagnosis was not greater than the baseline. The examiner further stated that "[t]he claimant reports that the 2017 spinal operation relieved most of the lower back pain and the shooting pain he had down legs. He continues to have the previous chronic lower back pain." In February 2021, Dr. D.C. provided an opinion stating that the Veteran's claimed condition/diagnosis was not at least as likely as not aggravated beyond its natural progression." The accompanying rationale was largely the same as the rationale provided by Dr. D.C. for the right knee opinion that was quoted in depth above and which therefore will not be repeated here. Additional rationale specific to the low back included that the Veteran "is diagnosed with degenerative arthritis of the spine, and had back surgery in 2017[.] I cannot overlook however how many years have occurred since the initial incident with his [left] knee in 1970 until when back conditions started being noted in records of 40+ years." It was again stated that "[b]eing 60+ years old and obese, the degenerative arthritis is expected to be naturally occurring." A conclusion was provided that "[l]ess likely than not low back disability is aggravated beyond natural progression by [service connected left] knee." Additionally of record are extensive VA and private medical records. In general, while such records variously noted pain and reflected treatment for the Veteran's low back, they did not provide either a nexus between the Veteran's current low back disability and his active service or state that his current low back disability was caused or aggravated by his service-connected left knee disability. Specific relevant records included a private November 2004 record from Family Care of Black Mountain, which noted a complaint of low back pain, stated that such "has been occurring in a persistent pattern. The course has been without change" and included an assessment of lumbago. A private January 2005 record from the same provider noted a complaint of back pain and stated that "[t]he onset of the pain has been gradual and has been occurring in an intermittent pattern for years. The course has been recurrent." Various other records from the same provider, to include dated in December 2011, noted a complaint of back pain and stated that "there has been no...trauma." A September 2012 VA primary care note was for the Veteran's initial visit and noted a repot of chronic lower back pain. Other VA treatment records referenced the Veteran having back symptoms for over 40 years, dating back to approximately the early 1970s. See September 2012 Note ("states has [history] of back problems [for] 40 years"); October 2012 Note ("reports he injured his back [over] 40 years ago when he slipped and fell...reports he had a laminectomy in 1973 and has had difficulty with pain since then"); December 2014 Note (noting low back pain "ongoing: for 40 years"); March 2015 Note ("has had chronic low back pain since the 1970's"). Analysis Direct Service Connection With respect to the first element of direct service connection, various evidence, to include the VA examinations discussed above, noted a current low back disability. As such, the first element has been met. With respect to the second element of direct service connection, while the Veteran's STRs did not contain records reflecting treatment for the low back, the October 2015 and August 2019 VA Back Conditions DBQs noted that the "Veteran states he initially injured his back when he injured his left knee in [approximately] 1968." As such, the second element has been met. With respect to the third and final element of direct service connection, the key issue is whether there is a nexus between the Veteran's current low back disability and service. The Board finds that competent evidence did not show such a nexus. See 38 C.F.R. § 3.159(a)(1). In this regard, the Board finds the August 2019 VA opinion from Dr. B.D. to be the most probative evidence of record as to the issue of direct service connection nexus. This negative opinion was provided by a doctor following examination of the Veteran and review of relevant records and included a rationale in support of the conclusions provided that, essentially, a low back disability was not related to the Veteran's active service. The Board notes that there is not competent evidence contrary to the conclusion provided by this negative opinion. The Board also finds probative the October 2015, August 2019 and February 2021 VA opinions addressing secondary service connection that variously referenced risk factors for the Veteran's low back disability that were not directly related to his active service, to include pars defects, obesity and age. To the extent that the Veteran has contended that he has a low back disability that is related to his active service, he is not competent to provide an opinion as to the etiology of his low back disability, as this is a complex medical issue that would require education, training or experience to address. See 38 C.F.R. § 3.159(a)(1), (2); see generally Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As to this issue, the Board affords significantly more probative value to the August 2019 VA opinion that, as discussed above, indicated that, essentially, the Veteran's low back disability is not related to his active service. Overall, the Board finds that competent evidence did not indicate a nexus between the Veteran's current low back disability and his active service. As the third element of direct service connection was accordingly not met, the Board finds that service connection on a direct basis is not warranted. Analysis Secondary Service Connection The key issue for secondary service connection is whether the Veteran's low back disability was caused or aggravated by his service-connected left knee disability. The Board finds that this was not shown by the most probative evidence of record. In this regard, as discussed above, of record are multiple VA opinions. The Board finds the October 2015 VA opinion from PA J.J. (addressing secondary service connection causation), the August 2019 VA opinion from Dr. B.D. (addressing secondary service connection causation) and the February 2021 VA opinion from Dr. D.C. (addressing secondary service connection aggravation) to be the most probative evidence of record as to the issue of secondary service connection. These three negative opinions were provided by medical professionals following examination of the Veteran and/or review of relevant records and included rationales in support of the conclusions provided that, essentially, a low back disability was not secondary to the Veteran's service-connected left knee disability. The Board notes that there is not any clearly articulated competent evidence contrary to the conclusions provided by these negative opinions. The Board has considered the Veteran's contention that, essentially, his low back disability is secondary to his service-connected left knee disability. The Veteran, however, is not competent to provide an opinion as to this issue, as this is a complex medical issue that would require education, training or experience to address. See 38 C.F.R. § 3.159(a)(1), (2); see generally Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As to this issue, the Board affords significantly more probative value to the October 2015, August 2019 and February 2021 VA opinions that, as discussed above, indicated that, essentially, the Veteran's low back disability was not secondary to his service-connected left knee disability. The Board has also considered the Veteran's July 2020 statement that, essentially, his VA doctors told him that his low back disability was secondary to his service-connected left knee disability. While VA treatment records do not appear to document such opinion, the Veteran is competent to report what he was told by his VA doctors. As such, the Board has considered the Veteran's report of what he was told by his VA doctors. The Board, however, affords limited probative value to such evidence, as there was no rationale provided in support of the reported opinion. By contrast, the Board affords significantly more probative value to the October 2015, August 2019 and February 2021 VA opinions, which, as discussed above, contained fully articulated rationales to support the conclusions provided. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Overall, the Board finds that the most probative evidence did not indicate that the Veteran's low back disability was caused or aggravated by his service-connected left knee disability. As such, the Board finds that service connection on a secondary basis is not warranted. Analysis Chronic Disease Presumption The Board finds that the evidence did not indicate that arthritis of the low back was shown as chronic in service, that such disability manifested to a compensable degree within the presumptive period of one year or that such disability was noted in service with continuity of symptomatology. As such, the Board finds that service connection based on the presumption regarding chronic diseases is not warranted. Conclusion In sum, the Board finds that the Veteran's low back disability did not have its onset during active service and is not otherwise related to active service. Overall, the Board finds that the preponderance of the evidence is against the claim and that the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is not warranted for a low back disability. 3. Service connection for a right hip disability Evidence The Veteran's STRs did not contain any treatment or complaints related to the right hip. The Veteran's April 1971 separation examination report noted upon clinical evaluation that the lower extremities and "spine, other musculoskeletal" were normal, noted no relevant defects or diagnoses and noted that the Veteran was qualified for release from active duty. Relevant lay statements from the Veteran raised the issue of secondary service connection between the Veteran's claimed right hip disability and his service-connected left knee disability. In this regard, on his June 2014 NOD, he stated "Right Hip, secondary to Left Knee." In a September 2020 statement, the Veteran stated that "I feel that my whole problems were caused by the injury to my left leg. This is also the conten[t]ion voiced by my doctors at the VA hosp[ital]." VA treatment records also included similar contentions. See March 2017 Note (noting that the Veteran "states, 'I think my hip pain is coming from compensating for m[y] knee pain'"); October 2019 Note ("Veteran states he had left knee replaced in July and is doing great in terms of his knee but because he favored left leg the right hip now feels like it's 'out of joint.'"). The Veteran was afforded multiple VA examinations and multiple VA opinions were obtained relevant to this claim. The Veteran was afforded a VA examination in October 2015 and a Hip and Thigh Conditions DBQ was completed by PA J.J. A diagnosis was noted of right hip osteoarthritis, with a date of diagnosis noted of 2014. Under the medical history section, it was noted that "Veteran states he began having right hip pain 4-5 years ago and he continues to have it. He states he believes it is from favoring his [service-connected] left knee." PA J.J. also provided an opinion that "[t]he condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition." The accompanying rationale stated: Reference to the NIH site on [DJD], and a current search of PubMed shows the following risk factors: aging, genetics, overweight, previous fractures or injuries to the specific joint, and repetitive activities to the damaged joint such as squatting or twisting. Review of the literature, including NIH, does not support [DJD] (arthritis) specifically causing [DJD], in another joint, neither directly, nor due to favoring the unafflicted joint because of pain in the injured joint. It is therefore less likely that the Veteran's...DJD right hip...is proximately due to or the result of his DJD left knee [status post] meniscectomy. The Veteran was also afforded a VA examination in August 2019 and a Hip and Thigh Conditions DBQ was completed by Dr. B.D. A diagnosis was noted of right hip osteoarthritis. Under the medical history section, it was noted that the Veteran "says he developed right hip pain over 5 years ago. The discomfort began rather abruptly." Dr. B.D. provided an opinion that "the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness." The accompanying rationale stated that "[STRs] do not document an in-service injury or condition likely to result in or predispose to development of hip pathology or the diagnosed right hip osteoarthritis (Fowles. Report of Med Exam 9 Apr 71, Pollard. Long Beach Naval Hospital Narrative Summary 4 Jun 70)." Dr. B.D. also provided an opinion that "[t]he claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected condition." The accompanying rationale was largely the same as the rationale provided by Dr. B.D. for the right knee opinion that was quoted in depth above and which therefore will not be repeated here. Additional rationale specific to the right hip, with citations to medical literature omitted, included: In this case the [V]eteran has evidence of right hip injury in a 2004 motorcycle accident and obesity, both well established causes of joint osteoarthritis...Being overweight is particularly associated with development of osteoarthritis...According to the Arthritis Foundation, the hip bears six pounds of pressure for every pound gained. Therefore, even an extra 10 pounds, over the course of many years, can add significantly to the wear and tear on a hip joint. Thus hip injury, aging, and obesity/excessive obesity are more likely to have caused the right hip arthritis in his case. Dr. B.D. also provided an opinion attempting to address secondary service connection aggravation. The opinion appeared to indicate that the Veteran's low back disability had not been aggravated. In this regard, the examiner marked a checkbox indicating that they could "determine a baseline level of severity of (claimed condition/diagnosis)...prior to aggravation or the earliest medical evidence following aggravation" and also marked a checkbox indicating that the current severity of the claimed condition/diagnosis was not greater than the baseline. The examiner further stated that "[t]he claimant continues to have right anterior hip pain with various activities and mild limitation in hip range of motion." In February 2021, Dr. D.C. provided an opinion stating that the Veteran's claimed condition/diagnosis was not at least as likely as not aggravated beyond its natural progression." The accompanying rationale was largely the same as the rationale provided by Dr. D.C. for the right knee opinion that was quoted in depth above and which therefore will not be repeated here. Additional rationale specific to the right hip included that "I cannot overlook however how many years have occurred since the initial incident with his [left] knee in 1970 until when right hip conditions started being noted in records of 40+ years." It was again stated that "[b]eing 60+ years old and obese, the degenerative arthritis is expected to be naturally occurring." A conclusion was provided that "[l]ess likely than not right hip disability is aggravated beyond natural progression by [service connected left] knee." Additionally of record are extensive VA and private medical records. In general, while such records variously noted pain and reflected treatment for the Veteran's right hip, they did not provide either a nexus between the Veteran's current right hip disability and his active service or state that his current right hip disability was caused or aggravated by his service-connected left knee disability. Specific relevant records included a private September 2004 ER Report from Memorial Mission Hospital, which referenced a motorcycle accident, noted a complaint of right hip pain and an assessment of right hip strain/contusion. A private January 2005 record from Family Care of Black Mountain, which noted a complaint of hip pain and stated that "[t]he onset of the pain has been gradual and has been occurring in an intermittent pattern for years. The course has been recurrent." A September 2012 VA primary care note was for the Veteran's initial visit and noted "new onset r[igh]t hip pain; approx[imately] 1 month ago." A later September 2012 note included an assessment of "[right] hip pain...neg[ative] xray of hip." A still later September 2012 note stated "[complains of] right hip pain [for] 1 month. [N]o known injury." A December 2014 note stated regarding pain "located: r[igh]t hip, left knee, low back, no new trauma[,] ongoing: for 40 years." An October 2019 orthopedic note from Dr. C.N. stated "2-1/2 months status post left total knee replacement. Advancing activity and mobility as best possible. Overall, he is quite pleased with his improvement with the left knee. He has having some pain over the lateral aspect of his right hip/greater trochanteric region" and noted an assessment of "[p]rogressing well following left total knee replacement" and "[t]rochanteric bursitis due to alteration of gait." A July 2020 orthopedic note from Dr. C.N. noted upon physical examination a normal gait and noted an assessment of "[a]ge-appropriate osteoarthritis bilateral hips." Analysis Direct Service Connection With respect to the first element of direct service connection, various evidence, to include the VA examinations discussed above, noted a current right hip disability. As such, the first element has been met. With respect to the second element of direct service connection, the Veteran's STRs did not contain records reflecting treatment for the right hip. It is also not clear that the Veteran has reported an in-service event, as the October 2015 and August 2019 VA Hip and Thigh Conditions DBQs described post-service onset of hip pain and did not mention in-service events. As such, it is not clear that the second element has been met. In any event, with respect to the third and final element of direct service connection, the key issue is whether there is a nexus between the Veteran's current right hip disability and service. The Board finds that competent evidence did not show such a nexus. See 38 C.F.R. § 3.159(a)(1). In this regard, as discussed above, of record are multiple VA opinions. The Board finds the August 2019 VA opinion from Dr. B.D. to be the most probative evidence of record as to the issue of direct service connection nexus. This negative opinion was provided by a doctor following examination of the Veteran and review of relevant records and included a rationale in support of the conclusions provided that, essentially, a right hip disability was not related to the Veteran's active service. The Board notes that there is not competent evidence contrary to the conclusion provided by this negative opinion. The Board also finds probative the October 2015, August 2019 and February 2021 VA opinions addressing secondary service connection, which variously referenced risk factors for the Veteran's right hip disability that were not directly related to his active service, to include "right hip injury in a 2004 motorcycle accident," obesity and age. To the extent that the Veteran has contended that he has a right hip disability that is related to his active service, he is not competent to provide an opinion as to the etiology of his right hip disability, as this is a complex medical issue that would require education, training or experience to address. See 38 C.F.R. § 3.159(a)(1), (2); see generally Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As to this issue, the Board affords significantly more probative value to the August 2019 VA opinion that, as discussed above, indicated that, essentially, the Veteran's right hip disability is not related to his active service. Overall, the Board finds that competent evidence did not indicate a nexus between the Veteran's current right hip disability and his active service. As the third element of direct service connection was accordingly not met, the Board finds that service connection on a direct basis is not warranted. Analysis Secondary Service Connection The key issue for secondary service connection is whether the Veteran's right hip disability was caused or aggravated by his service-connected left knee disability. The Board finds that this was not shown by the most probative evidence of record. In this regard, as discussed above, of record are multiple VA opinions. The Board finds the October 2015 VA opinion from PA J.J. (addressing secondary service connection causation), the August 2019 VA opinion from Dr. B.D. (addressing secondary service connection causation) and the February 2021 VA opinion from Dr. D.C. (addressing secondary service connection aggravation) to be the most probative evidence of record as to the issue of secondary service connection. These three negative opinions were provided by medical professionals following examination of the Veteran and/or review of relevant records and included rationales in support of the conclusions provided that, essentially, a right hip disability was not secondary to the Veteran's service-connected left knee disability. The Board notes that there is not any clearly articulated competent evidence contrary to the conclusions provided by these negative opinions. The Board has considered the Veteran's contention that, essentially, his right hip disability is secondary to his service-connected left knee disability. The Veteran, however, is not competent to provide an opinion as to this issue, as this is a complex medical issue that would require education, training or experience to address. See 38 C.F.R. § 3.159(a)(1), (2); see generally Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As to this issue, the Board affords significantly more probative value to the October 2015, August 2019 and February 2021 VA opinions that, as discussed above, indicated that, essentially, the Veteran's right hip disability was not secondary to his service-connected left knee disability. The Board acknowledges the October 2019 VA orthopedic note that included an assessment of "[t]rochanteric bursitis due to alteration of gait." This note, however, does not explain what the cause of the alteration in gait was and therefore did not indicate that the bursitis was secondary to the service-connected left knee disability. Moreover, even assuming (without deciding) for purposes of this decision that this note can be taken to mean that bursitis was secondary to alteration in gait that was itself due to the service-connected left knee disability, there was no rationale provided in support of this statement. The Board has also considered the Veteran's July 2020 statement that, essentially, his VA doctors told him that his right hip disability was secondary to his service-connected left knee disability. While VA treatment records do not appear to document such opinion, the Veteran is competent to report what he was told by his VA doctors. As such, the Board has considered the Veteran's report of what he was told by his VA doctors. The Board, however, affords limited probative value to such evidence, as there was no rationale provided in support of the reported opinion. By contrast, the Board affords significantly more probative value to the October 2015, August 2019 and February 2021 VA opinions, which, as discussed above, contained fully articulated rationales to support the conclusions provided. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Overall, the Board finds that the most probative evidence did not indicate that the Veteran's right hip disability was caused or aggravated by his service-connected left knee disability. As such, the Board finds that service connection on a secondary basis is not warranted. Analysis Chronic Disease Presumption The Board finds that the evidence did not indicate that arthritis of the right hip was shown as chronic in service, that such disability manifested to a compensable degree within the presumptive period of one year or that such disability was noted in service with continuity of symptomatology. As such, the Board finds that service connection based on the presumption regarding chronic diseases is not warranted. Conclusion In sum, the Board finds that the Veteran's right hip disability did not have its onset during active service and is not otherwise related to active service. Overall, the Board finds that the preponderance of the evidence is against the claim and that the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is not warranted for a right hip disability. Romina A. Casadei Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Hoopengardner, 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.