Citation Nr: 1432344 Decision Date: 07/18/14 Archive Date: 07/22/14 DOCKET NO. 09-03 391A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for a low back disorder REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from March 1987 to June 1990. This appeal comes before the Board of Veterans' Appeals (Board) from a September 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Little Rock, Arkansas that declined to reopen a claim for service connection for a low back disorder. The Veteran testified at a hearing before the undersigned Veterans Law Judge by videoconference from the RO in December 2010. A transcript of the hearing is associated with the claims file. In March 2011, the Board in part reopened the claim and remanded for further development. In March 2011, the Board denied service connection for a low back disorder. In that decision, the Board also denied a rating in excess of 40 percent for a cervical spine disorder and granted a rating of 50 percent, but not higher, for migraine headaches. The Veteran appealed the denial of service connection for a low back disorder to the U.S. Court of Appeals for Veterans Claims (Court). In December 2013, the Court vacated that portion of the decision regarding the low back disorder and remanded the appeal for compliance with a November 2013 Joint Motion for Partial Remand. The Veteran did not appeal the decision on the rating for migraine headaches, and the Court dismissed the appeal on the rating for the cervical spine. Therefore, these issues are no longer before the Board on appeal. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The Veteran also has an electronic Virtual VA paperless claims file. A review of the documents in Virtual VA reveals that such are either duplicative of the evidence in the VBMS file or are not to the issues on appeal. FINDINGS OF FACT 1. The Veteran has a current chronic low back disorder, diagnosed as degenerative disc disease with stable disc herniation at L4-5 and L5-S1. 2. The weight of credible lay and medical is that the Veteran chronic lumbar spine disease and disc herniation first manifested greater than one year after active service and were not caused or aggravated by any aspect of service including motor vehicle and commissary accidents or are secondary to his service-connected cervical spine disorder. CONCLUSION OF LAW The criteria for service connection for a low back disorder are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA must notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). A notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The burden of showing harmful error rests with the party raising the issue, to be determined on a case-by-case basis. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). In July 2006, the RO provided notice that met the requirements. The notice advised the Veteran of all criteria to substantiate a claim for service-connection on a direct basis and the reasons for the previous denial of the claim in March 1998. The notice explained the Veteran's and VA's respective responsibilities to obtain relevant evidence. At that time, the Veteran's cervical spine disease was not service-connected. Although the Board subsequently requested a medical opinion regarding secondary service connection, the Veteran consistently asserted that his low back disorder was caused by direct trauma during active service, and neither the Veteran, nor his representative, nor the record raised the issue of service-connection on a secondary basis. VA's duty to assist the Veteran in the development of the claims includes assisting him in the procurement of service medical records and pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that the RO appropriately assisted the Veteran in obtaining indicated treatment and evaluation records, including both VA and private records. The RO also informed the Veteran, including in the appealed rating action, subsequent rating actions, and by a statement of the case, supplemental statements of the case, of records obtained, and thus by implication of records not obtained, in furtherance of his claims. VA's duty to assist the Veteran by providing examinations when necessary was also adequately fulfilled. The Board finds that the multiple medical examinations afforded the Veteran in the course of appeal - in October 2008, November 2008, January 2010, and April 2011, and their findings and analysis taken together with the balance of the evidence of record, are adequate for the Board's adjudication herein. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The examinations provided sufficient detail, and supported their conclusions with analyses fully supported by review of the evidence presented, which analyses are readily weighed against contrary evidence. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). Further, the evidence so considered by the examination report and addendum was sufficient and encompassed the evidence of record. Id. The Board accordingly concludes that no further examination is required to support the Board's adjudication of the claim for service connection for a low back disorder. The Board also considered several opinions by private physicians submitted by the Veteran. The VA examinations, taken together with records of VA and service treatment, as well as private treatment records, and statements by the Veteran, as well as other evidence of record, are adequate for the Board's adjudication. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The examinations, taken as a whole, addressed both the medical findings upon current examination and the Veteran's history. The examination reports presented findings and conclusions reasonably consistent with the Veteran's medical history and the balance of contemporaneous medical records, and sufficiently addressed the medical criteria for low back disorder service connection to allow the Board to adjudicate the claim based on informed medical findings and medical judgment. The Board also finds that requirements of the Board's prior remand in March 2011 have been substantially fulfilled. This included updating the medical evidentiary record, obtaining medical examinations addressing medical questions underlying these claims, and readjudicating the claims by the RO. Only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998). D'Aries v. Peake, 22 Vet. App. 97 (2008). The Veteran has not indicated the existence of additional pertinent evidence. The case presents no reasonable possibility that additional evidentiary requests would further the appealed claim. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, supra. A Veterans Law Judge who chairs a hearing must fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. 38 C.F.R. 3.103(c)(2) (2013); Bryant v. Shinseki, 23 Vet. App. 488 (2010), Here, during the December 2010 video conference hearing, the undersigned Veterans Law Judge adequately explained the claims on appeal and suggested evidence that may support these claims, including evidence that the Veteran might submit that may have been overlooked. The Board accordingly concludes that the hearing requirements were effectively satisfied. To the extent any such notice may have been inadequate, this was effectively cured both by actual knowledge as evidence by statements and questions of the Veteran's authorized representative at the hearing and by the discussion of the case in a June 2012 and April 2014 Informal Hearing Presentations, and as well as by the Board providing such explanation of issues and suggesting submission of evidence in the March 2011 remand the Board issued to develop these claims. In view of the foregoing, the Board finds that all notification and development actions needed to render a decision on the Veteran's claim on appeal have been accomplished. II. Analysis The Veteran served as a U.S. Navy hospitalman apprentice. He contended in written statements in December 2006, January 2008, September 2011, in reports to his private physicians and to VA examiners, and in testimony at a December 2010 Board hearing that his current low back disorder was caused by traumatic injuries to his lower back in 1988 and 1989 during active service. He further asserted in an undated statement received in January 2010 that his medical training and expertise is sufficient to demonstrate competence in providing a medical opinion on the etiology of his lumbar spine disease. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Certain chronic disabilities, to include arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service personnel records showed that after recruit training, the Veteran completed Navy basic hospitalman and field medicine training. He was assigned to a naval air station hospital for duty, although treatment records indicated that one accident occurred while the Veteran was working in a commissary. Service treatment records showed that the Veteran sought treatment for neck and back pain following a motor vehicle accident in December 1987. A chest X-ray was normal, and there are no associated clinical notes in the file. A record of screening for confinement in March 1988 showed that the Veteran reported no complaints. In an undated report, a clinician noted the Veteran's report of neck and back pain following a motor vehicle accident the previous evening. The Veteran asserted that he was hit by a car coming directly toward him, but denied any specific injury. A cervical spine X-ray was normal, and the clinician diagnosed a contusion. However, in late July 1988, the Veteran again sought treatment for neck pain for the previous two and one-half weeks. He referred to a vehicle accident in January 1988 and also in March 1988. It is not clear exactly when one or more accidents occurred, but there is no record of emergency room treatment on either occasion. During this treatment encounter, the clinician noted "trigger" points in the scapular area and some "tightness" on motion in the lumbar area. The clinician prescribed heat and ultrasound treatment and diagnosed cervical myositis but did not note a diagnosis for the lumbar spine. In October 1988, the Veteran again sought treatment for severe low back pain that he had experienced for three days. There was no mention of the previous vehicle accidents or other causes. The clinician diagnosed acute lumbosacral strain and returned the Veteran to full duty. In late March 1989, the Veteran received emergency room treatment after slipping and falling on a wet floor while handling crates of milk at the commissary. The Veteran reported pain in the center of the low back and an abrasion on the left leg. The examining physician noted muscle spasms of the scapular musculature and tenderness of the thenar eminence. There was no mention of a head or neck injury. The next day, an examiner noted no head lesions, diagnosed musculoskeletal pain, the prescribed pain medication and light duty for one week. About six weeks later, the Veteran reported that his back pain was getting more severe. An examiner noted diffuse tenderness over the entire spine and diagnosed possible strain. However, the examiner noted that the symptoms "seem embellished" and ordered back exercises. The Veteran was examined twice during the following week with continued low back pain with no improvement with exercise and medication. The attending physician noted "suspect 2º gain" and continued to prescribe exercise and heat. In January 1990, the Veteran reported experiencing cervical pain and stiffness since being hit on the head in March 1989. An X-ray showed congenital fusion at C6-7 but there were no imaging studies or mention of symptoms of the lower back. Ultimately, the Veteran underwent medical evaluation and physical evaluation board reviews for cervical spine strain but no other disabilities. The Veteran received an early medical discharge. Regrettably, a discharge physical examination form is in the records but is entirely blank except for a review by a dentist. After discharge from active duty, the Veteran sought VA compensation for a cervical spine disorder and was examined in November 1990. The Veteran reported the March 1989 fall when he asserted that he injured his neck. He reported that he wore a cervical collar for approximately three weeks and was treated with pain medication. The Veteran did not report having injured his back in that fall. He described localized pain in his neck as well as headache, but did not report any difficulties of the back. An X-ray of the lumbosacral spine obtained in November 1990 was normal, and musculoskeletal examination also produced no finding of abnormalities of the lumbar spine. During an April 1993 VA examination, the Veteran reported that he worked performing heavy labor as a trackman for the Union Pacific Railroad. In an April 1995 VA examination, the Veteran reported that he was still working for the railroad. He did not complain of any low back difficulties. During a February 1996 treatment evaluation, the Veteran reported a history of gradually worsening neck pain over the previous three or four years but did not mention low back symptoms. In April 1996, a VA clinician noted the Veteran's report of chronic back pain and a lump on his back with no recent traumatic injury. The clinician diagnosed a seroma that was excised. Otherwise, he prescribed rest and medication for pain. During a VA joints examination in May 1996, the Veteran reported that in 1988 he slipped on a ramp while moving crates of milk and hit his head. He added that he was then knocked unconscious for a short time and since that time had increasing neck difficulties as well as headaches and difficulties sleeping. There was no mention of low back injuries or current symptoms. During a VA examination in December 1997, the Veteran reported that while working in the commissary in 1988 moving crates he slipped and the crates landed on top of him, injuring his cervical spine. He did not allege low back injury. The Veteran reported cervical pain, upper extremity neurological symptoms, and headaches but no symptoms of the low back. For the first time after active service, in March 1997, a VA clinician noted the Veteran's report of low back pain, muscle spasms and stiffness after bending forward while playing basketball the previous day. The clinician diagnosed musculoskeletal back strain. Later the same month, the Veteran reported increasing low back pain since that injury, and reported that he began experiencing a feeling of right leg weakness for the past two weeks. He denied a past history of low back problems. The attending physician noted that the possibility of osteoarthritis in the absence of an acute injury was unlikely. During a VA hospitalization over a number of days in May 1997 for psychiatric and illicit substance issues, the Veteran reported sustaining a cervical neck injury when he was riding in a helicopter that suddenly lost altitude and "exerted approximately 10 Gs of force causing a herniated disk." The examiner further noted, "The Veteran also reported a recent low back injury consist[ent] with a strain which is reported to be on the right side[,] and [the Veteran] is enrolled in physical therapy currently." Listed problems in the hospitalization report included chronic low back pain. In March 1998, the RO denied service connection for low back pain because the service treatment records showed that his back strain was an acute event with no continuity of low back symptoms to the present. In April 2001, the Veteran sought VA treatment following a back injury at work. The Veteran reported radiating pain to the lower legs and numbness of the feet. The circumstances and severity of the injury were not recorded. VA lumbar spine X-rays were assessed as showing reversal of lumbar lordosis potentially related to muscle spasm or positioning, but without fracture, dislocation, disc rupture, or joint disease. During a VA spine examination in August 2002, the Veteran complained of constant posterior neck pain, but the examination report did not reflect complaints or findings of low back disability. In a June 2004 spine examination, the Veteran reported injury to the neck in service when several crates fell on him and knocked him out. The Veteran reported that he had awoken from the injury on his back, but the remainder of the examination addressed only the history and current status of the cervical spine. In an August 2006 VA spine examination, the Veteran addressed his headaches and consistently painful cervical spine. He reported that he worked for approximately five years as a laborer for a railroad up to two years prior to the examination. The Veteran reported attempting to return to work a year ago, but being unable due to inability to perform lifting required for the work. The remainder of the examination addresses only the cervical spine. In September 2006, the RO declined to reopen the claim for service connection for low back pain because no new and material evidence had been received. The Veteran expressed timely disagreement in December 2006. In January 2007, he withdrew the appeal of other claims but not the petition to reopen the claim for the low back pain. He renewed his notice of disagreement in January 2008, asserting that his service records reflected low back injury and that "I reported and complained time and time again of this pain in my lower back, but was ignored." In an April 2008 VA outpatient treatment encounter, a magnetic resonance image of the lumbar spine obtained the previous month showed a disc protrusion at L5-S1 with displacement of the nerve root. Another magnetic resonance image in May 2008 showed spinal canal stenosis and stable disc herniation at L4-5 and L5-S1. During an October 2008 VA spine examination, the Veteran again described the 1988 accident when he injured both his neck and back while pushing crates. The Veteran acknowledged that he had a poor recollection of injuries to his back but did recall pain following the injuries. Although he experienced gradual symptom improvement with medication and therapy, he reported that he continued to have back problems over the years. He complained of flare-ups with walking activities, with resulting back weakness and numbness in the right foot during flare-ups and relief with muscle relaxants and rest. On examination, the Veteran walked with a slow, guarded gait with use of a cane. While the spine had normal alignment, there were spasm and tenderness to palpation and limitation of motion. The examiner noted that the March 2008 imaging revealed disk herniation at L4-L5 and S1 and evidence of both degenerative joint disease and spinal stenosis. The examiner diagnosed degenerative joint disease / herniated nucleus pulposus of the lumbar spine with moderate chronic lumbosacral right radiculopathy. The October 2008 VA examiner reviewed the claims file and noted that examination following the in-service injury produced essentially normal findings, and that VA examinations for compensation purposes in years following service suggested normal back findings. The examiner also observed that post-service treatment records did not document any low back complaints until 1997, whereupon the Veteran reported injury during a basketball game. On the basis of this review of historical and objective evidence the examiner concluded that it was not at least as likely as not that the Veteran's current back problem was related to injury in service. He explained that the records showed that the injury in 1988 resolved with treatment and that there was no chronic lumbar spine disability at the time of discharge from active duty. VA examinations of the spine in the 1990s were silent for low back symptoms until the basketball injury in 1997. Degenerative disease and disc deficits were not identified until the imaging studies in 2008. The examiner did not mention the workplace injury in 2001. In November 2008, a VA neurologist noted a review of the claims file and noted the Veteran's report of the crate accident and neck back injury. The neurologist noted that the neck area was the focus of his symptoms and treatment until 1997 and found no evidence to connect the neck injury as a cause or aggravation of the low back. In a February 2009 statement of the case, the RO reopened the claim for service connection for low back pain but denied it on the merits in part citing the conclusions of the VA examiner in October 2008. At a November 2009 VA treatment the Veteran reported a very busy life, including working and being in school as well as having a family with seven children at home and another baby expected within two months. A clinician noted ongoing treatment of back pain reportedly well-managed with medication. In statement in May 2009, the Veteran's spouse and mother noted their observations of the Veteran's back muscle spasms and discomfort. In a January 2010 statement, the Veteran's wife reported that she administered massage to the neck, back, and legs due to muscle stiffness, spasm, and pain. The Veteran submitted a federal work record reflecting missed work in 2010 with sick or annual leave approximately nine days taken for low back difficulties. In a December 2010 Board hearing, the Veteran recounted the circumstances of the milk crate accident in 1988 but did not mention any motor vehicle accidents in service or the 2001 workplace accident. He testified that in the crate accident he landed on his tailbone and immediately complained about his low back but that it did not get much attention from examiners. He further testified that he continually complained about his low back for the rest of his active service and to VA examiners in the 1990s who just focused attention to his cervical spine. He testified that the back strain playing basketball was just an aggravation of an already weaken spine. He reported that a VA physician had told him that his cervical and lumbar spine disorders were all related. In March 2011, the Board reopened the claim and remanded with instructions to obtain another VA examination and any new VA and private treatment records. The Veteran was afforded another VA examination in April 2011. Service records were reviewed including of treatment following an injury reportedly to his neck and low back in 1988, with treatment records reflecting conservative care following the injury. During the April 2011 examination, the Veteran complained of chronic pain in the neck and the back, though more so in the neck, for the past nine to ten years. The examiner noted that the Veteran reportedly missed two to three weeks of work due to flare-up episodes over the past year. X-rays continued to show disc protrusions at L4-5 and L5-S1. The examiner diagnosed chronic lumbar sprain with spasm and herniated disc and also noted that the service and post-service treatment records did not show chronic low back pain immediately after the accident to 1997. He concluded that the current lumbar disc disease was not caused or aggravated by the accident in service or by the service connected cervical spine disease. This physician did not address the 2001 workplace injury. In a written statement in September 2011, the Veteran called attention to evidence that should have been considered in his initial 1998 claim, specifically that he injured his low back in two accidents: the motor vehicle accident in 1988 and the crate accident in 1989. He noted that post-service VA treatment records confirmed that he reported low back pain prior to the basketball injury in 1997, and he submitted additional evidence from his private physicians. In a clinical report in September 2011, a private physician noted that the Veteran had been treated by VA physicians but that he had been asked to provide a second opinion. The physician did not note a review of any records but summarized the history presumably from reports by the Veteran as follows. He noted that the Veteran sustained a lumbar spine injury in a 1988 motor vehicle accident with no further comment on the symptoms or treatment. He noted that the Veteran fell on his back at the time of a May 1989 crate accident and was treated with pain medication and authorized light duty. He further noted that the basketball injury was not a physical injury but only a symptomatic injury. Comparing the service and post-service events, the physician concluded that the basketball injury was not sufficiently severe as to cause herniated discs and therefore the motor vehicle and significant crate accident was the cause of the lumbar spine disability. He did not mention the workplace accident in 2001. In a letter in October 2011, a private rehabilitation medicine consultant did not note a review of any records but described the circumstances of a motor vehicle accident in service in detail presumably from the Veteran's reports. In that accident on an unspecified date, the Veteran's vehicle hydroplaned in water, spun several times, hit another vehicle, and then a telephone pole. The Veteran was treated in an emergency room but knew nothing other than he had no fractures. The physician also summarized the crate accident when the Veteran fell on his back and had ongoing low back pain since that time. The physician did review VA reports from 1996 in which the Veteran was treated for back pain and a lump and that X-rays after the basketball injury were negative. The physician performed a clinical examination and noted the results of the magnetic resonance imaging. He evaluated the two service events as "very significant injuries" without explanation and noted that the Veteran complained of back pain prior to the "not such a significant issue of shooting a basketball." He concluded that it is more likely that the current back disorder were caused by the service injuries than the basketball injury. He did not mention the workplace injury in 2001. In September 2012, the Board denied service connection for low back pain placing greatest probative weight on the opinion of the VA examiner in April 2011. Regrettably, the Board did not discuss the two private opinions. On appeal, the Court vacated the decision in December 2013 and remanded the appeal for compliance with the instructions in a Joint Motion for Partial Remand to consider the September 2011 private opinion. In October 2012, the rehabilitation medicine consultant referred to the Board's reliance on the April 2011 VA opinion and provided an additional opinion. He noted that he previously addressed the lumbar disc disease but wanted also to comment on the Veteran's back sprains and spasms. He noted that he now reviewed the Veteran's service records provided by the Veteran that clearly showed an injury in a 1988 vehicle accident and lumbar sprain injuries in the crate accident which he incorrectly noted to have occurred in May vice March 1989. He again found that the Veteran had back pain prior to the basketball injury which was only an exacerbation of the injuries incurred in 1988 and 1989. He did not address the 2001 workplace injury. As a preliminary matter, the Board finds that the Veteran and his family members are competent to report experiencing or observing symptoms such as back discomfort, and that the Veteran is competent to report on the circumstances of his various injuries. The reports of symptoms to clinicians are credible because they were generally accepted by the medical providers, although on at least one occasion, the description of the in service incident of 1989 were exaggerated. The Board also finds that the description of an automobile accident to a private physician in October 2011 involving head-on collisions with another vehicle and telephone pole is not credible in its severity because service records show that the Veteran sought treatment well after each of two accidents with no emergency treatment or specifics of the accident as would be expected in such a violent collision. The Veteran's report of a continuity of chronic low back pain since the events in service is also not credible as it is inconsistent with the service treatment records after these events and the VA records prior to 1997. The credibility of lay statements may not be refuted solely by the absence of corroborating medical evidence but this is a factor. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay evidence concerning continuity of symptoms after service, if credible, may be competent, regardless of the lack of contemporaneous medical evidence). Other factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). In this case, the Veteran was examined on many occasions following the claimed injuries during and after active service in which his cervical spine symptoms were reported and examined in detail. Significantly, he underwent a military medical board that specifically addressed his cervical spine when the Veteran could have called attention to lumbar spine symptoms arising from the same events. Likewise, the Veteran had opportunities in 1990, 1993, and 1996 to report low back symptoms to VA clinicians who were addressing his recurrent neck pain. Further, the Veteran reported that he worked for five years after service on a railroad performing heavy labor that would have been inconsistent with a chronic back disability. Finally, the Board finds that the Veteran is not competent to provide an opinion on the origin of his current spinal disease. Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters, supra. Regarding his medical training, the Veteran cites only his basic and field medicine Navy training with no mention of medical education or training prior to or after active service. Service records confirm that the Veteran attained only an apprentice level rate (E-2), did not receive any formal or on-the-job advanced skill training, and was not qualified as an independent duty corpsman. Basic hospitalman skills include assisting health care professionals in areas of administration, patient screening, intravenous therapy, venipuncture, and hemorrhage control in combat trauma but do not include diagnosis and determination of the etiology of orthopedic disease as would be expected of a physician or advanced practice nurse. See Hospital Corpsman Skills Basic (HMSB)/Tactical Combat Casualty Care (TCCC) Program, BUMED Instruction 1510.23C (24 Jun 2009). The Board finds that service connection for a low back disorder is not warranted because the weight of credible lay and medical evidence is that his chronic low back pain and disc disease first manifested greater that one year after active service and was not caused or aggravated by one or more motor vehicle accidents or the crate accident in service. The Veteran has been diagnosed with lumbar spine canal stenosis with herniated discs at L4-5 and L5-S1. Therefore, the requirement of medical evidence of a current disability is met. The service records do show treatment following two motor vehicle accidents in 1987-88 and the fall in a commissary warehouse in March 1989. Although the events did occur, the post-accident evaluations do not show significant low back injuries. In December 1987, an X-ray was negative, and there were no clinical notations and the Veteran reported no ongoing symptoms in March 1988. The same month, he sought treatment the next day after an accident but with no reports of a specific injury, and the examination addressed only the neck. In July and October, the Veteran received only minor treatment for back strain with no reference to the motor vehicle accidents. The Veteran did receive emergency treatment following the fall in 1989 but was diagnosed only with muscle strain. Notably, the clinicians did not obtain low back X-rays as would have been appropriate with a significant back injury. They later noted that the Veteran's reported symptoms seemed embellished, and the medical board in 1990 addressed only the cervical spine. It would be reasonable for the Veteran to clearly identify a chronic lower back disorder at that time as it would have potentially increased his medical severance award. Therefore, although the accidents did occur, the service records do not show more than low back muscle strains that required no immediate follow-up medication, therapy, or imaging studies. Regarding a possible nexus between the claimed in-service disease or injury and the present disease or injury, there are medical opinions both for and against this element of service connection. The Board finds that the opinions are not in relative equipoise. Despite a review of the records by the VA examiners and one of the private physicians, none addressed the severity and significance of the Veteran's workplace accident in 2001 after which he reported radiating pain to his legs. The Board places low probative weight on the opinions of the private physicians in September 2011, October 2011, and October 2012 for the following reasons. The physician in September 2011 summarized the circumstances of the accidents in service from the Veteran's reports without consideration of the timing and nature of treatment that he was provided in service, results of the medical board, or the VA examinations prior to 1997. He simply compared the Veteran's description of the accidents to the description of the basketball injury and found a nexus to service on the basis of elimination. He did not note awareness or comment on the workplace injury or the timing of the earliest imaging studies that did not show a chronic spinal disorder until 2008. Although the rehabilitation consultant noted a review of the service records, he likewise determined that the accidents in service were "significant" although the records do not support that level of severity. He further suggested that chronic back muscle strain had its origin in service without commenting on the absence of symptoms reported by the Veteran when he had the opportunity to do so or his years of work in heavy manual labor. He also did not address the Veteran's right leg numbness after the basketball injury or make any mention of the 2001 workplace accident. The Board places greater probative weight on the observations and opinions of the military physicians who evaluated the Veteran shortly after the accidents, the medical evaluation board, VA outpatient clinicians on many occasions from 1990 to 2008, and the VA examiners in October 2008 and April 2011. First, regarding the severity of the accidents, the Board places much greater weight on the observations, diagnoses, and prescribed treatment by the military clinicians and the medical evaluation board because they had the opportunity to question and examine the Veteran closer to the time of his injuries and in the context of providing treatment and assessing his ability to continue his military service. All episodes of low back pain resolved without long term therapy or diagnosis of a chronic disease. Restrictions of duty were temporary. The Board places greatest weight on the opinions of the VA examiners in 2008 and 2011. Even though they too did not address the 2001 workplace accident, their evaluation of the severity of the accidents and the onset of chronic symptoms are most closely in agreement with the history of treatment during and after service. The Board need not speculate on whether the basketball injury, workplace injury, or any other post-service event was the cause of the current spinal disease. However, the weight of competent and credible lay and medical evidence is that the back strains in service were acute, did not suggest to clinicians the need for imaging and therapy, and were resolved at the time of discharge. The Veteran was able to work successfully for many years in a job that demanded manual labor. The Board considered the Veteran's lay statements that he continually reported his low back pain but was ignored by treating clinicians. This assertion is not consistent with many clinical encounters during service and after service prior to 1997 when the Veteran had the opportunity to report his low back symptoms. It is not reasonable that so many different clinicians or the military medical board would all simply ignore his complaints especially in the context of examining similar symptoms of his cervical spine. It is particularly evident because the Veteran was serving at a Navy hospital and would have had prompt access to care had he experienced persistent back pain. Finally, the Veteran has not claimed and nothing in the record suggests that the Veteran's current low back disorder was caused or aggravated by the service-connected cervical spine disorder. The Veteran asserted that the two disorders "were related" but the Board places greater weight on the opinions of the VA neurologist and VA examiner in 2008 and 20111 respectively who determined that the lumbar spine disease was not caused or aggravated by the cervical spine disability. The weight of the competent and credible evidence demonstrates that the Veteran's low back disorder including lumbar spine stenosis and herniated discs first manifested many years after service and is not related to his active service including one or more motor vehicle accidents or a fall while working in a commissary. As the preponderance of the evidence is against this claim, the "benefit of the doubt" rule is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a low back disorder is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs