Citation Nr: 21041319 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 17-01 141 DATE: July 8, 2021 ORDER Service connection for a right ankle disability, to include as secondary to service-connected right knee disabilities, is denied. FINDINGS OF FACT 1. The Veteran's right ankle disability did not manifest in service and is not otherwise related to his service in the U.S. Navy from 2001 to 2006, to include to his documented in-service shin splints. 2. The Veteran's right ankle disability was not caused or aggravated by his service-connected right knee disabilities. CONCLUSION OF LAW The criteria have not been met for service connection for a right ankle disability, to include as secondary to service-connected right knee disabilities. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303(a), (d), 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active duty service in the U.S. Navy from July 2001 to January 2006. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision issued by an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). In June 2019, the Board remanded the appeal for further development. This case has since been returned to the Board for appellate review, after the AOJ substantially complied with the Board's remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). Finally, the AOJ also issued a Statement of the Case (SOC) denying the Veteran an increased rating for his right knee disabilities, among other issues. However, after the SOC, the Veteran did not submit a Substantive Appeal (e.g., VA Form 9 or equivalent statement) for these particular issues. See 38 U.S.C. § 7105(a); 38 C.F.R. §§ 20.200, 20.202, 20.302(b) (2018) (redesignated as 38 C.F.R. §§ 19.20, 19.22, 19.51, 19.52(b), effective February 19, 2019). Thus, since the Veteran failed to perfect his appeal for these particular issues, they are not on appeal before the Board. I. VA's Duty to Notify and Assist VA's duty to notify under the Veterans Claims Assistance Act of 2000 (VCAA) was satisfied by VA letters sent to Veteran, dated in March 2017, October 2017, and November 2019. See 38 U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159 (2020). These notice letters advised the Veteran of the criteria necessary to establish entitlement to direct service connection and secondary service connection. In any event, subsequent to the ameliorative June 2019 Board remand, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist for the present appeal. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). One issue worth noting is that in a December 2019 Report of General Information (VA Form 27-0820), the Veteran advised that he would be completing medical authorization forms (VA Form 4142 and VA Form 4142a) in order for VA to secure relevant private treatment records. However, a review of the claims file reveals the Veteran failed to submit these medical authorization forms to the VA or to adequately identify the private providers in question. On this point, the Court has reaffirmed that the duty to assist is not a one-way street. Martinez v. Wilkie, 31 Vet. App. 170, 178 (2019). If a claimant wishes help, he or she cannot passively wait in those circumstances where his / her own actions are essential in obtaining the putative evidence. Hayes v. Brown, 5 Vet. App. 60, 68 (1993). Under VA regulation, a claimant is required to cooperate fully with VA's reasonable efforts to obtain relevant private records. 38 C.F.R. § 3.159(c)(1). In the present case, despite VA's efforts, neither the Veteran nor his representative cooperated with the necessary development to secure any additional private treatment records for his right ankle disorder claim. Therefore, the Board will proceed with adjudication of the claim. II. Service Connection (SC) The Veteran has not alleged that his right ankle disability began during service or is otherwise associated with service. Instead, he has alleged that his right ankle disability is secondary to his service-connected right knee disabilities. However, the AOJ considered direct service connection for the Veteran's right ankle disability as well. And previously, the Board in its June 2019 remand requested that a VA examiner address whether the Veteran's right ankle disability is associated with his period of service in the Navy. When determining service connection, all theories of entitlement, direct and secondary, must be considered if raised by the evidence of record, applying all relevant laws and regulations. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). As such, in the instant case, the Board will address the theory of direct service connection for a right ankle disability as well. 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) the existence of 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 disease or injury incurred or aggravated during service the "nexus" requirement. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). VA is to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Thus, there is no categorical rule that medical evidence is required when the determinative issue is either medical etiology or a medical nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Board should make explicit findings regarding the competency and, if necessary, the credibility of the lay evidence of record. Miller v Wilkie, 32 Vet. App. 249, 257-262 (2020). Lay testimony is competent to describe the presence of readily observable features or symptoms of injury or illness that are not medical in nature, such as varicose veins, tinnitus, and flat feet. See 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303, 307-310 (2007). The Federal Circuit has also clarified that lay evidence can be competent for the diagnosis or etiology of a condition if: (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1316. See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). And if the disability is of the type for which lay evidence is competent, the Board must weigh the probative value of that lay evidence against other evidence of record in making its determination regarding the award of service connection. Buchanan v. Nicholson, 451 F.3d 1331, 1334-37 (Fed. Cir. 2006). In determining whether service connection is warranted, on either a direct or secondary basis, the Board shall consider the benefit-of-the-doubt doctrine. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1991). The claimant is entitled to the benefit of the doubt when the evidence is in approximate balancei.e., "nearly equal"there is no requirement that the evidence be in exact equipoise. Lynch v. McDonough, __ F.3d __, No. 2020-2067 (Fed. Cir. June 3, 2021). However, if the preponderance of the evidence weighs against the claim, the evidence is not nearly equal, and the benefit-of-the-doubt rule does not apply. See Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Upon review of the evidence, the Board denies the appeal for direct service connection for a right ankle disability. The first and perhaps most fundamental requirement for any service-connection claim is proof the Veteran has a current disability. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a); Degmetich v. Brown, 104 F.3d 1328, 1332 (1997). In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). On this point, the Federal Circuit Court has also held that pain alone may constitute a disability, even without an identifiable underlying pathology, provided that such pain is productive of functional impairment. Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). In this case, September 2018 and January 2020 VA ankle examiners diagnosed the Veteran with residuals of a right ankle fracture, status post multiple right ankle surgeries. Specifically, VA and Tricare and UC Davis treatment records confirmed the Veteran fractured his right ankle in June 2014. He underwent an open reduction and internal fixation (ORIF) surgery with hardware placement for bimalleolar right ankle fracture and syndesmosis repair in June 2014. Subsequently, he had to undergo corrective right ankle removal of hardware (ROH) surgery in September 2015. The VA examiners observed that at present, his current right ankle symptoms include right ankle pain, limited range of motion, decreased strength, and swelling. He utilizes a right ankle brace as needed. He also takes Ibuprofen as needed. He experiences flare-ups of right ankle pain at times. Thus, it is undisputed the Veteran has current residuals of a right ankle fracture. He therefore meets this threshold criterion for service connection. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). The remaining question is whether symptoms of a right ankle disability first manifested in service from 2001 to 2006 or are otherwise related to this period of service in the Navy. Initially, the Veteran's particular residuals of his right ankle fracture are not one of the enumerated "chronic disease[s]" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions based on "chronic" symptoms in service and "continuous" symptoms since service at 38 C.F.R. § 3.303(b) do not apply here. Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). Importantly, VA X-rays for the right ankle dated in August 2014, September 2015, and September 2018 failed to reveal post-traumatic arthritis of the right ankle, which is listed as an enumerated "chronic disease" under 38 C.F.R. § 3.309(a). It follows that instead, 38 C.F.R. § 3.303(a) and (d) apply in the present case for the right ankle disorder on appeal. That is, the Federal Circuit has held that diseases that would be considered "chronic" in a medical sense like residual symptoms of a right ankle fracture, but which are not listed in 38 C.F.R. § 3.309(a) as an enumerated "chronic disease," may still qualify for service connection under the three-element test for disability compensation described above in § 3.303(a). Walker, 708 F.3d at 1338-39. Also, under 38 C.F.R. § 3.303(d), disorders diagnosed after discharge may also still be service connected if all the evidence, including pertinent service records, establishes the disorder was incurred in service. See Combee, 34 F.3d at 1043. As to the second requirement of in-service incurrence, the Veteran's service treatment records (STRs) dated from 2001 to 2006 are negative for any complaint, treatment, or diagnosis of a right ankle disorder. During service, STRs did document a right knee injury and bilateral shin splints. Also, STRs documented an acute left ankle injury. But STRs failed to reveal any right ankle injury or disorder. Thus, the Veteran's STRs dated from 2001 to 2006 provide no evidence in support of the in-service incurrence of a right ankle disorder. See 38 C.F.R. § 3.303(a). Post-service, with regard to lay evidence, the Veteran is competent as a lay person to report continuing, persistent symptoms of a right ankle disorder onwards after his service in the Navy ended in 2006. See 38 C.F.R. § 3.159(a)(2); Jandreau, 492 F.3d at 1377. But the Veteran has not done so in the present case. That is, post-service, there is no lay assertion from the Veteran or any clinical evidence of record suggesting or demonstrating frequent and persistent symptoms of a right ankle disorder subsequent to his separation from the Navy in 2006. In fact, the Veteran has consistently reported that the onset of his right ankle problems began post-service in June 2014, after he fractured his right ankle by stepping into an uneven depression on a beach. See e.g., March 2015 NOD (VA Form 21-0958) with accompanying statement; January 2017 VA Form 9; December 2016 and December 2019 Reports of General Information (VA Forms 27-0820); and September 2018 VA ankle examination. In summary, there is no lay assertion from the Veteran or any clinical evidence of record suggesting or demonstrating frequent and persistent symptoms of a right ankle disorder subsequent to his separation from the Navy in 2006, until over a decade later. In this regard, a prolonged period without medical or lay complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In short, this long period without lay or medical evidence of a right ankle disorder weighs against the direct service connection claim. Post-service, as to third requirement of a nexus, there is probative medical evidence of record that clearly weighs against a link between the Veteran's current right ankle disorder and his period of service in the Navy from 2001 to 2006. Holton, 557 F.3d at 1366. See also 38 C.F.R. § 3.303(a), (d). In this regard, a January 2020 VA ankle examiner (who is a VA physician assistant), after an interview and physical examination of the Veteran, as well as a review of the record, opined that the Veteran's right ankle disability was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. In making this determination, the VA examiner noted that the Veteran's STRs had been reviewed. Regardless, the Veteran sustained his right ankle fracture post-service in 2014. Moreover, in a June 2020 VA addendum opinion, a VA staff physician, after a review of the record, assessed that it is "less likely than not" that the Veteran's closed fracture of the right ankle was incurred in or caused by his episode of shin splints during service. The rationale was that there was no well-accepted medical evidence that links in a cause-to-effect manner shin splints to bi-malleolar ankle fractures. The VA physician added there was no evidence to link in any related or causative manner a period of shin splints experienced many years prior to a mechanical right ankle fracture injury resulting from a post-service fall in 2014. Importantly, there is no contrary medical opinion of record on the issue of direct service connection. As such, the January 2020 and June 2020 VA medical opinions provide strong evidence against direct service connection for a right ankle disability. Accordingly, the preponderance of the evidence is against the Veteran's service connection claim for a right ankle disability on a direct basis. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). This issue is therefore denied. III. Secondary Service Connection (SSC) In the alternative, the Veteran has asserted that his right ankle disorder is caused or aggravated by his service-connected right knee disabilities. In other words, he has contended that his right ankle disorder is secondary to his service-connected right knee disabilities. Specifically, he has explained that in June 2014, instability from his service-connected right knee caused his right knee to give out, while jogging on rocky, uneven ground of a beach. As a result of his service-connected right knee instability, he stumbled and fell on the uneven surface, with his right ankle getting caught in a depression. He thus fractured his right ankle during the incident. But the right ankle fracture would not have occurred, absent his service-connected right knee instability, according to the Veteran. He has pointed out that a short time after his corrective right ankle surgeries in June 2014 and September 2015, he had to undergo right knee surgery in January 2017 to correct the instability present in his right knee. See March 2015 NOD (VA Form 21-0958) with accompanying statement; January 2017 VA Form 9; and December 2016 and December 2019 Reports of General Information (VA Forms 27-0820). At present, the Veteran is service connected for the underlying disabilities a right knee strain, with a 10 percent rating in effect since January 20, 2006; a right knee reduced extension, with a 0 percent rating in effect since October 7, 2016; and a right anterior cruciate ligament (ACL) repair scar, with a 10 percent rating in effect since May 21, 2009. In addition, the existence of a current right ankle disability is undisputed, as already discussed in detail above. That is, September 2018 and January 2020 VA ankle examiners diagnosed the Veteran with residuals of a right ankle fracture, status post multiple right ankle surgeries. As such, the Veteran clearly meets this threshold criterion for service connection of a current right ankle disability. See again 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). When determining service connection, all theories of entitlement, direct and secondary, must be considered if raised by the evidence of record, applying all relevant laws and regulations. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). A disability can be service connected on a secondary basis if it is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(a). To be service connected on a secondary basis under a causation theory, the primary disability need not be service connected, or even diagnosed, at the time the secondary condition is incurred. Frost v. Shulkin, 29 Vet. App. 131, 138 (2017) (holding that there was not a temporal requirement inherent in 38 C.F.R. § 3.310(a) for claims for service connection on a secondary basis). Moreover, secondary service connection may also be established, by any increase in severity (i.e., aggravation) of a nonservice-connected condition that is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. A VA medical opinion regarding both the causation and aggravation facets of a secondary service connection claim must be provided in a secondary service connection claim. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under § 3.310(b)). Moreover, when addressing secondary service connection, a VA medical opinion should not combine causation and aggravation; separate findings and rationale should be provided for each one. Atencio v. O'Rourke, 30 Vet. App. 74, 90-91 (2018). In short, in order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) probative evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Upon review of the evidence of record, secondary service connection for a right ankle disability is denied. The claims file contains a mix of favorable and unfavorable medical opinions and clinical evidence on whether there is a secondary relationship between the Veteran's current right ankle disability and his service-connected knee disabilities. 38 C.F.R. § 3.310(a), (b); Atencio, 30 Vet. App. at 90-91. The Board has a duty to analyze the credibility and probative value of the evidence of record. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). That is, the Board must determine, as a question of fact, both the weight and credibility of the evidence. See Southall-Norman v. McDonald, 28 Vet. App. 346, 356 (2016). Equal weight is not accorded to each piece of evidence contained in a record; every item does not have the same probative value. The Board must analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, account for the evidence that it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez, 22 Vet. App. 295 (2008). Also, a VA examiner must consider the Veteran's relevant lay statements regarding a nexus and whether they are consistent or inconsistent with medical knowledge. Miller v Wilkie, 32 Vet. App. 249, 258-60 (2020). It is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons or bases. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). With regard to the unfavorable evidence against secondary service connection for a right ankle disability, a January 2020 VA ankle examiner (a VA physician assistant), proffered a negative opinion. The VA examiner noted the Veteran sustained a bimalleolar right ankle fracture in July 2014. By his own report, the Veteran was running when he slipped on dirt and stepped into a depression in the ground, causing the right ankle fracture. The Veteran reported to the VA examiner that his service-connected right knee condition caused him to fall, which resulted in the fracture of the right ankle. According to clinical evidence of record, the VA examiner observed the Veteran underwent right knee surgeries in 2001, 2008, and 2009. However, there were no documents in the claims file after the 2009 revision surgery for the right knee demonstrating the existence of right knee instability after the 2009 surgery. Furthermore, the VA examiner reasoned that stepping on uneven terrain is a common mechanism that can cause an ankle fracture, which the Veteran reported was the cause of the injury. Bearing one's weight of the body on uneven ground would cause excessive strain to the ankle joint resulting in the ankle fracture. There is no established relationship in the available record that would indicate that the right ankle injury was caused by instability of the service-connected right knee joint. Given this information and lack of supporting documented evidence in the claims file, the January 2020 VA examiner opined the Veteran's right ankle disability was less likely than not (less than 50 percent probability) caused by or proximately due to or the result of his service-connected right knee condition. With regard to the unfavorable evidence against secondary service connection for a right ankle disability, the January 2020 VA ankle examiner (a VA physician assistant) also opined that it was less likely than not that the Veteran's right ankle fracture was aggravated beyond its natural progression by his service-connected right knee condition. There was no documentation in the record to support this theory of entitlement per the VA examiner. No relationship between these two conditions has been established. There was no baseline level of severity for the right ankle because a right ankle condition did not exist until the June 2014 injury, according to the January 2020 VA ankle examination. With regard to the unfavorable evidence against secondary service connection for a right ankle disability, a June 2020 VA addendum opinion for the right ankle was secured by a VA staff physician. The June 2020 VA examiner also opined that it was less likely than not that the Veteran's right ankle disability was related to or caused by or secondary to his service-connected right knee condition. This VA examiner went into great detail in proffering her negative opinion. She explained that the mechanism of action causing the Veteran's right ankle fracture (medial distal tibia displaced fracture involving the right medial ankle joint and oblique fracture distal fibula shaft extending into ankle joint from the June 2014 radiographs) in all accounts of record was running and stepping into a divot / hole. This forceful mechanical stress in unstable ground caused this injury, with forces of running translating to his ankle hitting the ground in an inversion and eversion action, causing the bi-malleolar fractures that required surgical repair. There was no history and no evidence of preceding right knee pain or right knee instability in the years preceding the injury. In fact, he was running when the injury occurred, hence increasing the downward mechanical forces that caused the bi-malleolar fracture of his right ankle. The VA examiner added that the medical history and medical evidence of right knee instability came "AFTER" his right ankle fracture, demonstrated in a November 2016 MRI of the right knee. The mechanical forces causing his right bi-malleolar ankle fracture could have contributed to reports of right knee instability, but "NOT" the other way around. There was no evidence of instability of his right knee "PRIOR" to his running and stepping into a divot / hole on June 2014, hence eliminating any causation or aggravation of his right ankle fracture. With regard to the unfavorable evidence against secondary service connection for a right ankle disability, the June 2020 VA ankle examiner (a VA staff physician) also opined that it was less likely than not that the Veteran's right ankle fracture was aggravated beyond its natural progression by the service-connected right knee condition. The VA examiner surmised there was no medically based explanation that would link in an aggravation manner his right ankle fracture healing and status by a post ankle fracture development of right knee instability. When both the January 2020 and June 2020 VA medical opinions are considered in conjunction with each other, the analyses were extremely thorough (especially the analysis of the June 2020 VA examiner), based on a review of the evidence of record, supported by the clinical evidence of record, and supported by a detailed rationale. Both VA clinicians also considered the Veteran's lay assertions and reported history in the context of the entire evidentiary record. In this regard, the Court recently held that the duty to assist requires that a VA examiner "address the veteran's lay statements to provide the Board with an adequate medical opinion," in part because "medical opinions can inform credibility findings." Miller, 32 Vet. App. at 258. Also, an adequate medical opinion should discuss the specific facts and circumstances of a veteran's case (which both VA clinicians correctly did). Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018). The Court has stated that an examination or opinion is adequate when it sufficiently informs the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012). This too was met here. Both VA clinician opinions are entitled to significant probative weight against the secondary service connection claim for a right ankle disability. Although not perfect (in that the claims file contained evidence of some right knee instability in 2008 and 2009 prior to and immediately after the March 2009 corrective right knee surgery), the VA clinician opinions are nevertheless based on a review of the relevant evidence of record and are clear enough in their language to provide strong evidence against the Veteran's secondary service connection claim for a right ankle disability. In addition, the January 2020 and June 2020 VA medical opinions correctly addressed both the causation and aggravation facets of the secondary service connection claim, with separate findings and rationale for both theories. El-Amin 26 Vet. App. at 140-41; Atencio, 30 Vet. App. at 90-91. With regard to the unfavorable evidence against secondary service connection for a right ankle disability, there is also strong supporting evidence in VA treatment dated from 2010 to 2014 records that weighs against a finding of secondary service connection. That is, prior to his March 2009 ACL tear surgery for the right knee, "persistent" instability in the right knee was assessed by VA clinicians. In addition, it is acknowledged that in the months immediately after his March 2009 ACL tear surgery for the right knee, a May 2009 Veteran statement and a December 2009 VA orthopedic examination continued to assess right knee laxity and instability. But all other clinical evidence of record dated between 2010 and 2014 failed to document any reoccurring instability in his service-connected right knee, prior to his June 2014 right ankle fracture. Specifically, at a March 2010 VA joints examination, the Veteran reported his right knee was getting better after his March 2009 surgery for same. At that time, he specifically denied "giving way or instability" in the right knee. Moreover, stability testing of the right knee was normal in March 2010. At an August 2010 VA physical medicine rehab outpatient note, the Veteran complained of bilateral shin numbness and tingling after his March 2009 right knee surgery. But there was no mention of right knee instability. In an August 2012 VA TBI note, the Veteran reported numbness and tingling in the front of his calves constantly for years, occurring after the March 2009 right knee ACL tear surgery. But there was no mention of right knee instability. In an August 2012 VA primary care note, the Veteran reported that his right knee "resolved," status post-surgery in March 2009. Once again, there was no mention of right knee instability. No other VA or private treatment records dated from 2010 to 2014 observed or treated the Veteran for any right knee instability. The Board can favor competent medical evidence over lay statements offered by the Veteran, as long as the Board neither deems lay evidence categorically incompetent nor improperly requires a medical opinion as the sole way to prove causation. King v. Shinseki, 700 F.3d 1339, 1344 (2012). Moreover, the Board can discount lay evidence in its role as factfinder if it weighs the evidence, finds the clinical evidence more probative, and provides an explanation with supporting reasons or bases. English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). It is completely within the Board's discretion to weigh the evidence and assign probative value to the evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Therefore, the Veteran's lay assertions that he had significant instability in the right knee from 2009 to 2014 is outweighed by the clinical evidence of record above. These medicals records were generated with a view towards ascertaining the appellant's then-state of physical fitness - they are akin to statements of diagnosis and treatment and are of increased probative value. Rucker v. Brown, 10 Vet. App. 67, 73 (1997). The absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded. Fountain v. McDonald, 27 Vet. App. 258, 272 (2015). In this regard, the Veteran was treated for a variety of medical conditions in VA treatment records dated from 2010 to 2014. It is highly unlikely that if he continued to experience persistent right knee instability after his March 2009 right knee surgery that he would fail to report this fact to VA clinicians, despite receiving medical treatment for a variety of other ailments during this timeframe. Furthermore, it was only subsequent to his June 2014 and September 2015 right ankle surgeries that VA and Tricare clinical records confirmed that the Veteran began to report right knee instability, ultimately requiring another corrective right knee surgery in January 2017. See e.g., November 2016 and December 2016 Tricare reports ("now has persistent instability in the knee"); November 2016 Tricare record (it was noted that after his 2008 and 2009 right knee surgeries the Veteran's right knee did "fairly well"); November 2016 VA treatment note (right knee is now "giving way" with "recurrent instability" but the Veteran did "fairly well for several years after his second surgery" [i.e., his March 2009 knee surgery]); November 2016 VA treatment note (instability seen on objective testing of the right knee); January 2017 private operation report (conservative treatment has failed as he complained of right knee instability, with operation necessary to improve his instability). Importantly, the Veteran did not report his right knee instability symptomatology in earlier VA treatment records dated from 2010 to 2014. He only began to report worsening instability in the right knee after his June 2014 and September 2015 right ankle surgeries. With regard to the unfavorable evidence against secondary service connection for a right ankle disability, when the Veteran was first treated for his right ankle injury at UC Davis Health System and at a VA Medical Center (VAMC) in June 2014, he failed to describe to any clinician on those occasions that the fracture of his right ankle was the result of right knee instability. That is, a June 22, 2014 VA nursing emergency department note documented "Pt came to ED stating that he was at the river and was chasing his daughter and foot fell in a "Pothole." PT states that he "put his leg together and pop bones in and out." In a June 23, 2014 UC Davis Health System treatment note, "[p]atient denies pain anywhere else" with the exception of the right ankle. Another June 23, 2014 UC Davis Health System treatment note remarked that right ankle pain began six hours earlier after the Veteran stepped in a hole and felt a crack, but "[p]atient without other injuries." A June 22, 2014 VA physician emergency department note that was written only one hour after the right ankle fracture occurred commented: "26 year old male presents with complaints of right ankle pain after running while in the water and stepping into a hole. He heard a pop and crack. Pain is rated moderate, not able to weight bear." A June 22, 2014 VA nursing emergency department triage note advised that while running the Veteran's right foot / ankle fell into a divot. His right ankle / distal foot was swollen, not in correct alignment. But there was no mention of the right knee. Another June 2014 UC Davis Health System treatment note found that on physical examination, there was no tenderness or crepitus at the midfoot or knee. In addition, June 23, 2014 UC Davis Health System X-rays for the right tibia / fibula showed "[p]ostsurgical changes of the right knee likely of ACL reconstruction noted." No other condition was assessed for the right knee at that time. Thee above medicals records contemporaneous to the time of the right ankle injury in June 2014 were generated with a view towards ascertaining the appellant's then-state of physical fitness, such that they are akin to statements of diagnosis and treatment and are of increased probative value. Rucker, 10 Vet. App. at 73. They are inconsistent with the Veteran's latter lay assertions regarding the presence of right knee instability at the time of the June 2014 right ankle fracture. See AZ v. Shinseki, 731 F.3d 1303, 1315 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). The Board acknowledges that in the January 2017 VA Form 9, the Veteran asserted that he failed to advise the private or VA clinicians of his right knee instability in the hours after the June 2014 right ankle fracture because he was focused on his significant pain. Also, the pain medication then administered clouded his thinking and made him tired. Despite these latter lay assertions explaining why he failed to report his right knee as the cause of right ankle fracture simultaneous to the injury in June 2014, the Board finds that more importantly statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment. White v. Illinois, 502 U.S. 346, 355-56 (1991). In this respect, contemporaneous evidence can have greater probative value than inconsistent lay testimony provided by the claimant at a later date. Curry v. Brown, 7 Vet. App. 59, 68 (1994). Thus, the Veteran's lay contentions on this particular point are not persuasive. The Board now turns to the medical evidence of record that supports secondary service connection for the right ankle. 38 C.F.R. § 3.310(a), (b); Atencio, 30 Vet. App. at 90-91. With regard to the evidence in support of secondary service connection for a right ankle disability, in a November 2016 Tricare report, the Veteran reported to that clinician that he did not feel like he can trust his right knee. He added that he recently fell while walking, resulting in a right ankle fracture (in June 2014), after his right knee buckled and he landed awkwardly. Additionally, in an October 2018 VA primary care note, a VA physician wrote that the Veteran "fractured right ankle 2015 when knee gave way." There was no further discussion in either of the clinical records cited above. No rationale was provided at either time. Although the Board may reject a medical opinion that is based on facts provided by the veteran that have previously been found to be inaccurate (see Reonal v. Brown, 5 Vet. App. 458 (1993)) and may reject such a medical opinion because other facts present in the record contradict the facts provided by the veteran that formed the basis for the opinion (see Swann v. Brown, 5 Vet. App. 229, 233 (1993)), the Board may not disregard a medical opinion solely on the rationale that the medical opinion was based on a history given by the veteran. Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005). In the present case, as discussed above, the credibility and probative weight of the Veteran's reported history that instability from his service-connected right knee resulted in his June 2014 right ankle fracture is unsupported by the other clinical evidence of record discussed in great detail above. In this vein, the Board may reject a medical opinion if the Board finds that other facts present in the record contradict the facts provided by the veteran that formed the basis for the opinion. Kowalski, 19 Vet. App. at 179. Moreover, the favorable November 2016 Tricare report and October 2018 VA primary care note did not provide any significant analysis or rationale. A mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision. Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007). A medical opinion must support its conclusions with analysis. Id. at 24. Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. Hernandez-Toyens, 11 Vet. App. at 382. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. Id. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As such, the above favorable Tricare and VA clinician opinions are entitled to limited probative value in support of the secondary service connection claim for a right ankle disability. None of these favorable medical opinions were supported by a detailed rationale. They included little to no reasoned analysis for their conclusory statements, thus limiting the probative value of their statements. The Court has stated that an examination or opinion is adequate when it sufficiently informs the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012). The above favorable opinions failed to meet this standard. Therefore, with regard to secondary service connection, these two favorable pieces of evidence are outweighed by the more detailed VA examinations / opinions and private and VA and Tricare treatment records discussed above. With regard to lay evidence of a nexus between the Veteran's right ankle disability and his service-connected right knee disabilities, lay persons are not categorically incompetent to speak on matters of medical diagnosis or etiology. Davidson, 581 F.3d at 1316. In this vein, the Board must consider the type of condition specifically claimed and whether it is readily amenable to lay diagnosis or probative comment on etiology. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (rheumatic fever is not a condition capable of lay diagnosis). The Veteran is indeed competent to report the timeframe of the development of his symptoms of his right knee and right ankle, as well as describe the symptoms themselves. See 38 C.F.R. § 3.159(a)(2); Barr, 21 Vet. App. at 307-09. However, his lay assertions regarding a secondary relationship are unpersuasive in light of the clinical evidence of record discussed in great detail above, demonstrating that instability from his service-connected knee disability did not cause his right ankle injury or worsen his right ankle disability. In sum, the Board finds that the preponderance of the evidence is against the Veteran's service connection claim for a right ankle disability on a secondary basis. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The secondary service connection issue for the right ankle disability is therefore denied. Romina A. Casadei Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P.S. Rubin, 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.