Citation Nr: 22017922 Decision Date: 03/27/22 Archive Date: 03/27/22 DOCKET NO. 13-29 434 DATE: March 27, 2022 ORDER Entitlement to service connection for left hip trochanteric bursitis, to include as secondary to a service-connected left ankle disability, is denied. Entitlement to service connection for a left knee disorder, to include as secondary to a service-connected left ankle disability, is denied. Entitlement to service connection for a right knee disorder, to include as secondary to a service-connected left ankle disability, is denied. FINDINGS OF FACT 1. The probative evidence of record is persuasively against finding that the Veteran's left hip bursitis first manifested in or is otherwise due to her active service; and is against finding that her service-connected left ankle disability resulted in an altered gait severe enough to cause or aggravate her left hip bursitis. 2. The probative evidence of record is persuasively against finding that the Veteran's left knee disorders first manifested in service or to a compensable degree within one year of separation; and is against finding that her service-connected left ankle disability resulted in an altered gait severe enough to cause or aggravate her left knee disorders. 3. The probative evidence of record is persuasively against finding that the Veteran's right knee disorders first manifested in service or to a compensable degree within one year of separation; and is against finding that her service-connected left ankle disability resulted in an altered gait severe enough to cause or aggravate her right knee disorders. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left hip disorder, to include as secondary to a service-connected left ankle disability, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for a left knee disorder, to include as secondary to a service-connected left ankle disability, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for entitlement to service connection for a right knee disorder, to include as secondary to a service-connected left ankle disability, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Air Force from October 1978 to November 1980. This matter comes before Board of Veterans' Appeals (Board) on appeal of a September 2011 decision issued by a regional office (hereinafter agency of original jurisdiction or AOJ) of the Department of Veterans Affairs (VA). The Veteran testified before the undersigned Veterans Law Judge at an August 2017 virtual hearing, a transcript of which has been attached to the record. The Board previously remanded this matter to the AOJ for further development in September 2017, October 2018, September 2020, January 2021 and September 2021. Service Connection The Veteran asserts that her current left hip and bilateral knee disorders are caused or aggravated by her service-connected left ankle disability, diagnosed as a chronic strain with increased laxity. She specifically claims that these disorders are due to increased stress caused by an altered gait used to overcompensate for left ankle instability and weakness. Generally, service connection will be granted if the Veteran has a disability resulting from personal injury or disease incurred in the line of duty, or for aggravation of a preexisting injury or disease incurred in the line of duty during active service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. Additionally, service connection may be granted on a secondary basis for a disability which is proximately due to or the result of an established service-connected disability. See 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that (1) a current disability exists; and (2) the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). To establish service connection, the evidence must show competent evidence of (1) a present disability, (2) an 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Whenever there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the veteran. 38 U.S.C. § 5107(b). Certain chronic diseases, such as arthritis, may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Moreover, if a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Id. However, if evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not "shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned," i.e., "when the fact of chronicity in service is not adequately supported," then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013) (quoting 38 C.F.R. § 3.303(b)). A claimant "can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in § 3.309(a)." Id. at 1337. 1. Entitlement to service connection for left hip trochanteric bursitis, to include as secondary to a service-connected left ankle disability Due to the similar nature of the Veteran's claims, much of the factual background will be discussed here. The Veteran's entrance examination indicates that she was evaluated as clinically normal. January 1981 service treatment records note she reported with a swollen left knee, although she denied specific trauma, stating she had been dancing. The treating clinician observed swelling with mild effusion and patellar tenderness, though no ligament damage. The diagnosis was recorded as "knee pain." The remainder of the service treatment records are silent for complaints of or treatment for knee or hip issues. Other than her left ankle injury, the only other instances in which the Veteran was placed on medical profile during active service were for her two pregnancies January 1982 service treatment records indicate the Veteran injured her left ankle while playing basketball. She was diagnosed with a severe ankle sprain, although x-rays were negative for a fracture. Her diagnosis was changed the next day to a "hyper inversion sprain," and during a followup the treating clinician observed edema and limited range of motion. A medical profile the following day noted an acute sprain of the ankle, assigned her crutches, and placed her on profile for five days with no standing, walking or running. The Veteran was afforded physical therapy, and records from 10 days after the initial injury indicate that she had full use of her left ankle with no signs of edema. February 1982 service treatment records note the Veteran was able to return to playing basketball as long as her left ankle was taped. March 2005 private treatment records include x-rays revealing what appeared to be mild degenerative changes in the Veteran's left hip. August 2005 MRI imaging revealed no intrinsic abnormality in the hips. April and May 2007 private treatment records note the Veteran's back disorder caused occasional pain and numbness in her left leg, but that her stance and gait were stable. December 2007 VA treatment records indicate that the Veteran was in a car accident which had caused now-resolved leg pain, and also describe her gait and stance as stable. The Veteran was afforded a June 2011 VA hip examination in which she was diagnosed with left hip trochanteric bursitis, causing increased pain and decreased stamina and mobility. The VA examiner opined that the Veteran's left hip disorder was less likely than not due to service, to include as secondary to her left ankle disability. The examiner reasoned that if the left ankle were to cause an altered gait the Veteran would have shifted her weight to her right side and that her left hip would be protected to a degree. Noting that the Veteran's right hip was clinically normal and that her symptoms were limited to the left side, the examiner concluded that her left ankle was not causing altered weight bearing significant enough to result in her left hip disorder. During December 2013 VA treatment, the Veteran reported that a private orthopedist thought that her low back pain was aggravated by an abnormal gait. The treating clinician noted that she was in a left leg immobilizer due to a recent left meniscus tear, and that she was going to be undergoing corrective surgery. January 2014 VA treatment records note that the Veteran described the onset of consistent left knee pain in September 2013 while she was doing a lot of walking in New York City, with swelling beginning in December. An MRI revealed a medical meniscus tear as well as chondromalacia of the patella. July, August and October 2015 private treatment records note that the Veteran demonstrated a stable stance as well as a brisk to stable gait, to include tandem gait. In August 2016 the Veteran submitted an article regarding the possible long-term effects of ankle sprains, which included chronic lateral ankle instability and possible muscle weakness higher in the leg as well as subsequent back and hip problems, including bursitis. In September 2016, the Veteran requested a nexus opinion from her private treatment provider. The Veteran described hearing a "pop" in her left knee during her inservice basketball injury and reported chronic aching and swelling in her knee after the incident. The provider noted medical records indicating the onset of left knee pain in the fall of 2013, and upon examination observed a mild limp in the left lower extremity. Based on this, the provider opined that the Veteran "sustained a permanent partial impairment of 60 percent of the whole body as a result of the [inservice] injury in 1982." April 2017 VA treatment records indicate the Veteran reported that her gait felt increasingly unsteady, as well as increased knee and ankle pain. During the September 2017 Board hearing, the Veteran related inservice back, knee and ankle injuries, but stated she didn't note any complaints during separation. She asserted her belief that her knee and hip problems were due to overcompensation for her unstable left ankle and described a 2014 left meniscus repair. The Veteran stated that she felt her condition was worsening and noted the article describing the long-term effects of ankle sprains. Her husband, a former nurse, testified that since 1990 he had noticed the Veteran manifest a limp when her ankle swells. January 2018 VA treatment records note that the Veteran reported increased pain and difficulty maintaining bilateral knee extension when heel to toe walking. The treating clinician noted she used no assistive aids, and April 2018 records note she "walks well with no gait aids." March 2019 VA treatment records note the Veteran exhibited normal muscle strength and tone with intact steady gait and balance. May and July 2019 records record a smooth gait with symmetrical arm swing. August 2019 VA records note she reported ambulatory with a steady gait, while those from November 2019 indicate she was provided with a cane to help with her gait, which the Veteran asserted was altered due to a right knee disorder. However, February 2020 VA treatment records noted she "walks well with no gait aids" and those from September 2020 describe her gait as steady and unassisted. The Veteran was afforded an additional VA hip examination in October 2020. The examiner reviewed the claims file and upon examination continued the diagnosis of left hip sub-trochanteric bursitis, noting the Veteran would have difficulty running, jumping, and squatting. The Veteran described her inservice left ankle injury and denied any right ankle injury, but reiterated her abnormal gait theory and stated, "everything is connected." The examiner opined that the Veteran's left hip disorder was less likely than not due to service, to include her inservice left ankle sprain. The examiner noted that the Veteran separated from service in 1984 and that her left hip disorder was diagnosed over 20 years later, while her service treatment records were silent with regard to treatment for or complaints of hip issues. The examiner acknowledged the September 2016 private opinion but observed that it presented a percentage of impairment with no supporting rationale or explanation of a causal connection between the Veteran's left ankle disability and her left hip disorder. The examiner did not address aggravation, noting there was no medical basis for a causal connection between the two conditions. During an April 2021 VA hip examination, the Veteran described her inservice left ankle injury and asserted that over time this led to left hip pain. Noting her generally stable gait, the April 2021 examiner opined that the Veteran's left hip disorder was less likely than not caused or aggravated by her left ankle injury. During a June 2021 VA examination, the Veteran's left ankle was evaluated as clinically normal. September 2021 VA treatment records note the Veteran ambulated with a steady gait. In November 2021, a VA examiner opined that the Veteran's left hip disorder was less likely than not due to her active service, as her service treatment records were silent for light duty, profile, or medical evaluation board associated with an acute or chronic left hip condition. The November 2021 examiner also opined that the Veteran's left hip disorder was less likely than not caused or aggravated by the Veteran's left ankle disability. The examiner noted that hip bursitis can have many causes, including excessive pressure on or movement of the joints, and that to cause this condition a left ankle disability would need to have caused an obvious gait abnormality in order to result in increased pressure on the hip joint. Observing that the Veteran's gait was described as without significant abnormalities during the examination, as well as during 2007, 2017, 2019 and 2021 examinations, the examiner concluded that such a mechanism to create excessive pressure on the hip was not present. The examiner specifically referenced an orthopedic surgery note from May 2007 which noted "physical exam with stable gait with mild limp- she ambulates well." The November 2021 examiner was unable to provide a baseline regarding aggravation due to a lack of medical evidence supporting such, concluding that "there is no clear objective evidence that the Veteran had sustained alteration in gait that would have been severe enough to create this condition." With regard to the article submitted by the Veteran referencing a "domino effect" of ankle sprains potentially leading to muscle weakness and bursitis, the examiner emphasized that although the Veteran has demonstrated a "slight limp," neither the observations made in treatment records nor those made by himself and his staff in the parking lot and upon examination indicated a limp that would be severe enough to cause or aggravate her left hip disorder. After review of the relevant evidence of record, the Board finds that the Veteran's current left hip disorder less likely than not first manifested in or is otherwise due to her active service. There is no evidence or lay report of a left hip injury during service, and no evidence indicating that her left hip bursitis manifested during her active service. Further, there is no note of a left hip disorder until August 2005 treatment records, which contain imaging revealing mild degenerative changes with no intrinsic abnormalities. As bursitis is not a chronic disease, continuity of symptomatology cannot substitute for a nexus between the disorder and service, which the evidence of record is persuasively against finding. The Board also finds that the probative evidence is against finding that the Veteran's left hip disorder is caused or aggravated by her service-connected left ankle disability. In this regard, the November 2021 VA opinion is highly persuasive. This examiner acknowledged the presence of a limp, but rationalized that the Veteran did not demonstrate a severe enough limp to cause additional disability. While acknowledging lay reports and records observing a limp in the Veteran's left leg, even if presumed as due to her ankle disability, the examiner cited to the actual records noting a stable and unimpaired gait in determining there was no medical link between the conditions. This examiner considered and discussed the medical treatise article and opinion the Veteran provided in support of her claim. This opinion is consistent with prior VA opinions which, while inadequate in certain aspects, provide similar reasoning. Conversely, the Board finds the September 2016 private opinion to be of little probative value with regard to the Veteran's left hip claim. As noted by the VA examiners, this opinion did not provide a supporting rationale for positing a 60 percent impairment of the Veteran's lower leg caused by her inservice ankle injury, nor did it state that this injury and subsequent disability caused or aggravated her current left hip disorder. See Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (favorable evidence which does little more than suggest possibility of causation is insufficient to establish service connection); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("most of the probative value of a medical opinion comes from its reasoning"). Similarly, the Board finds the Veteran's assertion that her inservice left ankle injury and resulting disability caused her to manifest an altered gait, thereby causing or aggravating her left hip bursitis, to have little probative value. While she is competent to report the onset and worsening of left hip pain, there is no indication she possesses the medical training and knowledge of the internal workings of the human body to opine on the nature and etiology of her hip disorder. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Therefore, the matter is beyond her competence as a lay person, and the Board places more probative value on the opinions of the VA examiners, who are medical professionals with subject matter expertise. The Veteran's husband, who has some medical training, has described limping during swelling episodes. The VA examiner considered the witness observations of a limp in the context of the entire record including recorded observations by different examiners over the years. The lay witness statement holds little probative value as to the issue of causal effect. The Board has also considered the Veteran's recollection that a doctor informed her that her gait abnormality was causing back pain. This recollection has some probative value in general, but the opinion is not specific to the hip and the rationale and reasoning for this assertion is not known. The probative value of this recollection is greatly outweighed by the November 2021 opinion which specifically discussed the basis for the opinion provided. Finally, although the August 2016 article describing the possible long-term effects of ankle sprains, to include hip bursitis, has some probative value, the Board finds that this value is outweighed by the specifically tailored opinion of the VA examiner, who reviewed the Veteran's personal medical history and lay statements before opining that based on the facts of this particular case any gait abnormality caused by her left ankle disability was not severe enough to cause or aggravate her left hip disorder. The Board finds this opinion to be highly persuasive on the matter. As such, there is no reasonable doubt to resolve in the Veteran's favor, and the claim is denied. 38 U.S.C. § 5107(b). 2. Entitlement to service connection for a left knee disorder, to include as secondary to a service-connected left ankle disability 3. Entitlement to service connection for a right knee disorder, to include as secondary to a service-connected left ankle disability In addition to the history discussed above, the Veteran was afforded a VA knee examination in June 2011, during which she was diagnosed with mild osteoarthritic changes in the bilateral knees, worse on the left, based on contemporary imaging. She reported an onset of knee issues around 2008, to include bilateral pain and swelling. The examiner opined that the Veteran's bilateral knee disorder was less likely than not due to her active service, noting that the January 1981 inservice incident of left knee pain and swelling apparently resolved with no further treatment in or post-service until her report of a 2008 onset of symptoms. The June 2011 examiner also opined that her knee disorders were less likely than not caused or aggravated by her inservice ankle injury, as the condition was bilateral in nature and no gait abnormality was noted in medical records, observed on examination or reported by the Veteran. The examiner rationalized that even if a gait disturbance were present, the Veteran's bilateral knee disorder could not be attributed to it given that imaging indicated that her left knee was worse than the right, since medically the worse findings would be expected on the knee opposite the ankle producing the gait change. Finally, the examiner observed that the Veteran was 52 years old, her knee degeneration was mild to moderate, and recent studies indicated that the average age of total knee replacement recipients was 59, leaving him unable to infer additional causation beyond age and genetics. As discussed further above, the Veteran reported the onset of increased knee pain during fall 2013 and in January 2014 was diagnosed with a medial meniscus tear and chondromalacia of the patella and underwent corrective surgery. The August 2016 article describing the "domino effects" of ankle sprains did not discuss knee problems. A September 2016 private opinion notes the Veteran reported hearing a "pop" in her left knee during her inservice basketball injury and that she experienced knee swelling after the injury. The private clinician observed a mild limp in the left lower extremity caused by left ankle laxity and noted that she also reported left knee pain beginning in the fall of 2013 after doing an extensive amount of walking. The clinician opined that "this patient sustained a permanent partial impairment of 60 percent of the whole body as a result of the [inservice] injury in 1982." The Veteran was afforded an additional VA knee examination in October 2020, which confirmed the diagnoses of bilateral osteoarthritis (left and right diagnosed in 2011 and 2013, respectively), and noted bilateral meniscal tears (2013 on the left, 2019 on the right), as well as a popliteal cyst in the right knee diagnosed in 2019. The Veteran stated that she recalled knee problems beginning "around 1985," reporting continued pain and difficulty walking and asserting her bilateral knee pain is caused by her left ankle sprain because "everything is connected." The October 2020 examiner opined that the Veteran's bilateral knee disorders were less likely than not due to her active service or caused or aggravated by her left ankle strain. The examiner stated that there was no medical literature to causally connect meniscal injuries, cysts or osteoarthritis to a left ankle disorder based on the examination findings and medical history. The examiner observed that there was no documentation of an alteration in gait or fall caused by the ankle disability, and that the private examiner resorted to speculation without supporting rationale or citation to the claims file when attributing a "60 percent" disability to her inservice ankle injury. The examiner also stated that the Veteran's assertion that "everything is connected" was not consistent with published medical literature or the facts of this individual case. During a June 2021 VA examination, the Veteran's left ankle was evaluated as clinically normal. The Veteran was afforded an additional VA knee examination in November 2021, during which she reported a 2006 onset of left knee pain, described as occurring gradually after injuring her left ankle. The examiner opined that the Veteran's bilateral knee disorder was less likely than not due to her active service, noting that the medical record is silent for a chronic or disabling knee disorder, that her January 1981 injury was not associated with any traumatic event, and that there were no further complaints of or treatment for knee issues through to her 1984 separation due to pregnancy. Finally, the examiner observed that the first note of a traumatic or disabling condition was 20 years after separation from service, when range of motion was normal with pain at endpoints of motion. The June 2021 VA examiner also opined that the Veteran's bilateral knee disorder was less likely than not caused or aggravated by her left ankle disability. Noting that while any lower extremity injury may result in an altered gait, the examiner stated it was not clear that the mechanism of ankle injury was severe enough to cause the development of a left knee disorder, and that it would be difficult to rationalize such a connection. Similarly, the examiner opined that there was no clear objective evidence indicating that the Veteran's left ankle disability caused an alteration in gait significant enough to create her right knee disorder. The examiner declined to speculate on a baseline level of aggravation, emphasizing that although the Veteran had at times demonstrated a "slight limp," neither the observations made in treatment records nor those made by himself and his staff in the parking lot and upon examination indicated a limp that would have been severe enough to cause or aggravate her bilateral knee disorder. After review of the relevant evidence of record, the Board finds that the Veteran's current bilateral knee disorders less likely than not first manifested in or are otherwise due to her active service. Although there is an instance of 1981 inservice knee pain and swelling, there was no trauma associated with incident, which appears to be transient since the remainder of her service records are silent for complaints of or treatment for signs or symptoms of a knee disorder. Further, there is no record of a knee disorder until June 2011 treatment records, which contain imaging revealing mild degenerative changes in both knees. As there is no evidence of the development of arthritis during or in the first year after separation, as well as no evidence of continuity of symptomatology the evidence of record is persuasively against finding a nexus between her knee disorders and service. The Board acknowledges that according to the March 2016 private opinion, the Veteran reported hearing a "pop" in her knee during her inservice ankle injury. The same clinician also noted that medical records indicate a fall 2013 onset of left knee pain. The Veteran also stated during the August 2017 Board hearing that she did not complain of knee issues until the 1990s, and during an October 2020 VA examination she reported an onset "around 1985," with continued pain and difficulty walking which she attributed to her left ankle sprain because "everything is connected. She has also provided onset dates of 2006 and 2008 for knee pain. The variation between 1985 to 2008 for the onset of chronic symptoms is more then two decades and highly unreliable. The fact that the Veteran has recalled the actual onset of knee symptoms differently and provided contradictory accounts on separate occasions tends to demonstrate either a failure of memory or a lack of integrity, and in either event it weakens and impairs the value of her testimony. See State v. Spadafore, 220 S.E.2d 655, 661 (W. Va. 1975) ("Generally, after a proper foundation has been laid, a witness may be impeached by evidence of his declarations or statements which are either inconsistent or contradictory to his testimony at trial). See also Seng v. Holder, 584 F.3d 13, 19 (1st Cir. 2009) (notwithstanding the declarant's intent to speak the truth, statement may lack credibility because of faulty memory). Therefore, the Board finds that to the extent the Veteran reports an inservice onset of a knee disorder or continuing symptoms since service, these statements have little probative value. In this case, the Board places greater probative value on the objective medical records indicating that the Veteran was not treated for knee issues after an isolated 1981 report of pain and swelling, as well as the cumulative opinions of the VA examiners indicating that there is no nexus between her current knee disorders and service. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant). As such, entitlement to service connection based on chronicity is not warranted. 38 C.F.R. §§ 3.307, 3.309. The Board also finds that the evidence is against finding that the Veteran's service-connected left ankle disorder caused or aggravated her current bilateral knee disorders. In so finding, the Board assigns the September 2016 private opinion little probative value. As noted above, the Board does not find the Veteran's report of an inservice onset for her left knee disorder to be probative, and the private clinician contradicts this report in his own assessment of the Veteran's medical history. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (noting that if the examiner relies on an inaccurate fact, then the opinion has little or no probative value). Finally, while the opinion posits that the Veteran manifests 60 percent impairment due to her inservice ankle injury, it does not indicate that either of her knee disorders are due to said injury and is therefore not persuasive on the matter. Stegman, 3 Vet. App. at 230. The Board also finds the August 2016 article describing the longer term "domino effects" of ankle injuries to have little probative value. Although this article discusses muscles higher in the leg losing strength, it does not list as possible consequences any of the Veteran's current left knee disorders, to include arthritis and a past meniscal tear, or discuss opposite leg disorders. Additionally, the article is general in nature and does not specifically relate to the facts and circumstances of this particular case. See Wallin v. West, 11 Vet. App. 509, 514 (1998). Similarly, the Board finds the Veteran's lay assertion that her inservice left ankle injury and residuals caused an altered gait which in turn resulted in her bilateral knee disorders to have little probative value. While she is competent to report the onset and worsening of bilateral knee pain, as discussed above these statements have been inconsistent, and as such are not credible. Additionally, there is no indication the Veteran possesses the medical training and knowledge of the internal workings of the human body to opine as to the nature and etiology of her bilateral knee disorders. See Kahana, 24 Vet. App. 428. Therefore, the matter is beyond her competence as a lay person, and the Board places more probative value on the opinions of the trained VA medical professionals. The Veteran's husband, who has some medical training, has described limping during swelling episodes. The VA examiners considered the witness observations of a limp in the context of the entire record including recorded observations by different examiners over the years. The lay witness statement holds little probative value as to the issue of causal effect. The Board has also considered the Veteran's recollection that a doctor informed her that her gait abnormality was causing back pain. This recollection has some probative value in general, but the opinion is not specific to the knees and the rationale and reasoning for this assertion is not known. The probative value of this recollection is greatly outweighed by the November 2021 opinion which specifically discussed the basis for the opinion provided. These VA opinions indicate that if the Veteran's left ankle injury residuals impacted her gait significantly enough to contribute to a knee disorder, such disorder would be expected to be worse in the right knee versus the left. However, as noted by the 2011 VA examiner, contemporaneous imaging of the Veteran's knees indicated that her right knee arthritis was less severe than her left, and her mild to moderate bilateral knee arthritis was not unusual for someone of her age. The VA examiners also observed that the majority of the Veteran's medical records described her gait as normal and opined that even the slight limp testified to or noted in some treatment records would not be severe enough to cause or aggravate her bilateral knee disorders. The VA examiners are medical professionals with subject matter expertise, and the Board finds their opinions to be cumulatively persuasive on the matter. While some of these opinions are inadequate in some aspects, the cumulative weight of the opinions greatly outweigh the claims. As such, the probative evidence of record is persuasively against finding that the Veteran's bilateral knee disorders are due to her active service or were caused or aggravated by her service-connected left ankle disability. There is no reasonable doubt to resolve in the Veteran's favor, and the claim is denied. 38 U.S.C. § 5107(b). T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. C. Schumacher, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.