Citation Nr: 0205560 Decision Date: 05/30/02 Archive Date: 06/11/02 DOCKET NO. 98-15 827 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUE Entitlement to service connection for a low back disorder. REPRESENTATION Appellant represented by: Don Hayden, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD N. W. Fabian, Counsel INTRODUCTION The veteran had active duty for training in the Wisconsin National Guard from March to July 1976 and active duty in the United States Marine Corps from March 1977 to June 1978. The Department of Veterans Affairs (VA) Regional Office (RO) initially denied entitlement to service connection for a low back disorder in September 1984. The veteran again claimed entitlement to service connection for a low back disorder on multiple occasions, resulting in a January 1988 decision by the Board of Veterans' Appeals (Board) denying service connection. The Board's January 1988 decision is final. 38 U.S.C. § 4004(b) (1982); 38 C.F.R. § 19.104 (1987). Based on an additional claim submitted by the veteran, in a July 1998 rating decision the RO determined that new and material evidence had not been submitted to reopen the previously denied claim. The veteran perfected an appeal of that decision. In an August 2000 decision the Board found that new and material evidence had been submitted and reopened the claim. The Board then denied the claim on the basis that it was not well grounded. 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000) (VCAA) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126) (West Supp. 2001). Among other things, this law eliminated the concept of a well-grounded claim and superceded the decision of the United States Court of Appeals for Veterans Claims (Court) in Morton v. West, 12 Vet. App. 477 (1999), withdrawn sub nom. Morton v. Gober, No. 96-1517 (U.S. Vet. App. Nov. 6, 2000) (per curiam order), in which the Court had held that VA cannot assist in the development of a claim that is not well grounded. The change in the law is applicable to all claims filed on or after the date of enactment of the act, or filed before the date of enactment and not yet final as of that date. VCAA, § 7, subpart (a). The veteran appealed the Board's August 2000 decision to the Court. Due to the passage of the VCAA, in a February 2001 order the Court vacated that part of the Board's August 2000 decision that denied service connection for a low back disorder and remanded the claim to the Board for re- adjudication in light of the VCAA. Because the Court did not vacate that portion of the August 2000 decision in which the Board found that new and material evidence had been submitted, that issue is not now before the Board. FINDINGS OF FACT 1. The RO has notified the veteran of the evidence needed to substantiate his claim, obtained all relevant evidence designated by the veteran, and obtained medical opinions in order to assist him in substantiating his claim for VA compensation benefits. 2. A chronic low back disorder was not shown in service; the low back disorder that was initially documented in June 1980 and arthritis of the spine many years later are not related to service. CONCLUSION OF LAW A low back disorder was not incurred in or aggravated by active service, nor may arthritis of the spine be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1112, 1131, 1137, 5107 (West 1991 & Supp. 2001); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2001). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background The service medical records show that in April 1976 the veteran was noted to have a history of Legg-Perthes' disease in the left hip. In August 1977 he reported having dropped a wall locker onto his right leg, resulting in an abrasion. He was hospitalized for the treatment of gastroenteritis in 1977 (the month of treatment is illegible). In September 1977 he complained of pain in both hips, with a history of hip problems for the previous 12 years. The pain was described as being in the iliac crest and across the anterior hips. The physical examination was negative, and an X-ray study revealed old, incomplete, slipped capitol femoral epiphysis, bilaterally. He reported in December 1977 having had hip problems since childhood, with an increase in symptoms since boot camp. An X-ray study was normal, and his complaints were assessed as bilateral hip pain of unknown etiology. During an orthopedic evaluation in January 1978, the veteran reported having had bilateral hip pain since infancy, which he was then experiencing with walking, running, or carrying packs. On examination he had a very flexible spine, and there was no evidence of sciatic notch or greater trochanter tenderness. The orthopedist requested X-ray studies of the hips and the lumbosacral spine. The request for the X-ray study indicates that the pertinent clinical history consisted of low back and hip pain with walking. The X-ray studies were negative. The veteran underwent a Medical Evaluation Board (MEB) in March 1978, which indicates that bilateral hip pain since infancy was noted when the veteran entered on active duty. The initial diagnosis of a slipped capital femoral epiphysis was not verified in the orthopedic evaluation, in that there was no X-ray evidence to support that diagnosis. The MEB noted that the diagnosis of chronic arthritis of the left hip had been rendered in December 1977, but that X-ray studies of the hips and lumbosacral spine were completely normal. The MEB found that the veteran had complained of consistent bilateral hip pain since boot camp, but that no specific diagnosis had resulted from multiple orthopedic evaluations. The MEB diagnosed the veteran's complaints as arthralgia of both hips, existing prior to enlistment and not aggravated by service. The MEB recommended that the veteran be discharged due to a condition that existed prior to enlistment and found that, on return to a more sedentary civilian life, no disability would exist. The service medical records are otherwise silent for any complaints or clinical findings pertaining to the low back. No complaints were registered in conjunction with the May 1978 separation examination and no abnormalities of the spine were found on examination. The veteran initially claimed entitlement to VA compensation benefits in June 1978, for a disability he described as a hip condition (arthritis). That claim was withdrawn shortly after it was filed because the veteran was attempting to re- enlist. He again claimed entitlement to compensation benefits for a hip condition (arthritis) in June 1981. He did not report having received any medical treatment since his separation from service. In conjunction with that claim, he submitted a statement from his spouse in which she reported that he had never complained of back pain prior to service, but that he began to complain of back pain in August 1978, when he was working for a block company and had to lift and carry heavy objects. An undated report from St. Mary's Medical Center indicates that the veteran complained of aches and pain all over, including the back. His complaints were then attributed to influenza and "arthritis," although no X-rays were included and the location of the "arthritis" was not described. The veteran also submitted treatment records from M. W. Nelson, M.D., showing that he had been treated for Perthes' disease of the left hip from October 1965 to February 1967. He was again treated for left hip pain in September 1974, when examination and X-ray studies were normal. In June 1980 he reported that he had experienced back pain for a long period of time, and that he had had back pain while in service. He again developed back pain while working in construction. On examination there was no evidence of muscle spasm. The physical examination and an X-ray study were essentially normal. His complaints were diagnosed as lumbosacral strain. In 1986 the veteran sought assistance from Dr. Nelson in obtaining disability benefits based on service, and then reported that he had developed arthritis in the hips and back while in service. Dr. Nelson stated that the veteran had also contacted him in 1980 to get evidence that he had arthritis in his back. Dr. Nelson stated that the veteran had not developed arthritis in the hips or back while in service, in that there was then no evidence of arthritis. Dr. Nelson referenced the X-ray study done in 1980, which revealed no evidence of arthritis in the back, and told the veteran that he was unable to help him. The veteran also presented treatment records from G. J. Sampica, M.D., indicating that in December 1981 he had recurrent back strains. He reported having been separated from service in 1978 due to chronic back pain. Dr. Sampica conducted a physical examination, which resulted in the finding that the veteran had no occupational limitations and could perform heavy labor on a full-time basis. Dr. Sampica stated that the veteran appeared to be in excellent health. On a July 1981 VA orthopedic examination, the veteran reported a number of musculoskeletal aches and pains that the examiner characterized as bizarre and related to alcohol abuse. The veteran then stated that he had been hospitalized for a month in January 1978 due to dysentery, when he complained of a back ache and generalized aches and pains. He had also been hospitalized in January 1981 at Racine, Wisconsin, for ethanol abuse. Reportedly, the veteran's description of his history was very confused, and he was unable to describe specific events in service. Objectively, the veteran was able to move all of the extremities fully and freely. There was normal lordotic curvature of the spine, and full range of motion of the spine, except for minimal restrictions at the extremes that the examiner attributed to moderate morbid obesity and neglect of physical fitness. X- rays of the lumbosacral spine, pelvis, and hips were negative. The diagnoses were residuals of alcohol abuse; moderate obesity and complete neglect of physical fitness; non-exertional musculoskeletal symptoms, suspicious of alcohol-related etiology. The veteran initially claimed entitlement to compensation benefits for chronic back pain in June 1984, which he attributed to arthritis. He then reported having received treatment through the state correctional system since May 1983. VA treatment records disclose that the veteran complained of morning stiffness in the back in January 1985 while undergoing a rheumatology evaluation for chronic shoulder pain. The stiffness was relieved by working, and he had been employed as a construction worker. In October 1985 he reported chronic arthritis in his back, and requested medication. The treatment provider found that he had a history of lumbosacral strain, and provided medication. The veteran again underwent a rheumatology evaluation in January 1986 due to shoulder pain, during which he reported a history of low back pain. Examination revealed full range of motion of the spine and extremities, normal deep tendon reflexes, good strength, and no tenderness. During a March 1986 hearing in conjunction with his claim for service connection for a bilateral hip disorder, the veteran testified that while in service he had fallen down a flight of stairs while carrying a locker, landing on his rear end and resulting in an injury to the calf. He stated that after the fall, he had pain in his hips and minor aching in the back. Additional VA treatment records indicate that in October 1986 the veteran reported having pain and stiffness in the back. The physical examination was negative for any objectively demonstrated pathology. The complaints were assessed as low back pain of unknown etiology. In January 1987 he reported having low back pain, and having had low back pain in service. A physical examination was normal, and X-ray studies of the lumbosacral spine, pelvis, and hips revealed no abnormalities. His complaints were attributed to mechanical low back pain. During a January 1987 physical therapy evaluation he reported having had low back pain since service, and that his then current employment required extensive bending. The physical therapist found that the pain was due to postural (mechanical) causes due to excessive flexed postures related to his employment. In May 1997 the veteran complained of intermittent back pain in the right lumbosacral area. An X-ray study was requested to assess degenerative joint disease and sacroiliitis. The X-ray study of the lumbar spine revealed spondylolysis of L5- S1 without spondylolisthesis, and disc disease at L5-S1. X- ray studies of the hips were unremarkable. The veteran reported having morning back stiffness in October 1997, which was assessed as degenerative joint disease at L5 based on the previous X-ray study. In multiple statements beginning in February 1998, the veteran asserted that the complaints documented in his service medical records, which had previously been attributed to a hip problem, were actually related to the low back. He claimed to have experienced chronic back pain during and since service. He also claimed to have received treatment for a back disorder while in the National Guard in 1976, and from the VA medical center (MC) since June 1978. He submitted a statement signed by his brothers and father in which they attested that the veteran had no health problems prior to service, but that his physical condition slowly deteriorated after he was separated from service. In conjunction with his most recent claim, the RO requested a medical opinion from William P. McDevitt, M.D., a VAMC Chief of Orthopedics, regarding the relationship, if any, between the veteran's currently diagnosed back disorder and an in- service disease or injury. Dr. McDevitt reviewed the evidence in the claims file, including the service medical records, and noted that no back complaints were documented during service and examination on separation from service revealed no evidence of a back disorder. Since separating from service the veteran had engaged in heavy labor, and his back complaints started in August 1978, two months after he was separated from service. The complaints in August 1978 were related to heavy lifting that he was doing at work. Multiple examinations and X-ray studies following his separation from service failed to reveal any objective evidence of a back disorder, including arthritis, and Dr. Nelson in 1986 found no relationship between the veteran's complaints and service. A recent X-ray study had revealed evidence of degenerative changes at L5-S1. Based on review of the evidence, Dr. McDevitt concluded that the veteran's back complaints were related to his occupation following his separation from service, that there was no evidence whatsoever of a back injury in service, and that there was no relationship between the currently diagnosed disorder and service. He also concluded that the low back disorder was not related to the hip disorder that was documented during service. The veteran presented hearing testimony before the undersigned in June 2000. He stated that he had not had any problems with his hips while in service, and he denied having injured his back while in service. He stated that he had a backache all the time while he was in service, and that when he asked the doctor to find out why his back hurt he ended up being separated from service. He also stated that although he thought the pain was in the hip while he was in service, he later found out that the pain had been in the low back. He denied having ever been told that the problems he was having in service were due to Perthes' disease, or having been given that diagnosis since his separation from service. He testified that he saw a doctor for an examination two months after he was separated from service. He also testified that he had been separated from service due to a low back problem. He stated that following his separation from service he had worked in construction labor, which he became unable to do due to back pain. He then worked in a machine shop, and was unable to perform that work because it required lifting. He started driving a truck, and had done so for the previous 10-11 years. Following the Court's February 2001 remand, the veteran's representative submitted a May 2001 medical opinion from Craig N. Bash, M.D., a neuroradiologist. Dr. Bash reviewed the veteran's medical records, interviewed him in April 2001, and concluded that the advanced degenerative arthritis originated from the veteran's service experience. He found that the September 1984 rating decision was erroneous, in that the veteran should have been rated for the degenerative changes at that time. He summarized the medical evidence from 1974 to April 2001, including the veteran's multiple reports of having had back pain during and since service. He concluded that the veteran had injured his back when he fell while carrying the wall locker, which caused the pain documented in the service medical records. He stated that the pain associated with standing and running that was documented during service was consistent with a low back injury, with radiating pain in the legs. He also found that the veteran had had back pain since service. He noted that X-ray studies since 1974 had shown no abnormalities in the hips, but that an X-ray study in May 1997 revealed degenerative changes in the spine. Dr. Bash found that the abnormalities documented in May 1997 were likely due to service related injuries because (1) the degenerative changes were more advanced than he would expect for a man of the veteran's age; (2) the arthritis was isolated to a single level, and did not represent a systemic process; (3) there was no evidence of any intervening spine injury; (4) the veteran had consistently stated that his pain began during service; (5) his symptoms had continuously worsened since service; (6) the hip films were normal, so that the in-service diagnosis of Perthes' disease was inaccurate; and (7) the veteran's symptoms during service and currently were consistent with the current X-ray findings. Dr. Bash cited to a reference indicating that it is well known that injuries to the spine early in life often lead to degenerative changes later in life. Dr. Bash took exception with Dr. McDevitt's opinion for the following reasons: (1) Dr. McDevitt did not take a patient history prior to rendering his opinion, because when Dr. Bash interviewed the veteran he very clearly identified the origin of his back problems as the fall with the wall locker; (2) Dr. McDevitt had not reviewed the veteran's X-rays, which clearly showed L5-S1 disease; (3) Dr. McDevitt did not discuss the relationship between the L5-S1 disease and the veteran's pain complaints; (4) Dr. McDevitt did not explain how the Perthes' disease could be problematic, in that the X- rays of the hips were normal; (5) Dr. McDevitt did not cite to any literature in support of his opinion. Due to the conflicting medical opinions regarding any relationship between the veteran's currently diagnosed low back disorder and service, the Board requested an additional medical opinion from a physician with the Veterans Health Administration. In a December 2001 report, Federico P. Girardi, M.D., an orthopedic surgeon who specializes in spinal surgery, provided the opinion that there was no relationship between the veteran's currently diagnosed low back disorder and service. Dr. Gerardi concluded that there was no objective evidence of the veteran having incurred a back injury during service, in that he was separated from service due to the hip disorder and a radiographic study of the back was normal. He noted that the first documented complaints pertaining to the back were in August 1978, two months following the veteran's separation from service, and related to his employment. His back complaints in January 1987 were also attributed to his employment. He noted that although degenerative changes were found by X-ray study in May 1997, no such changes had occurred on any previous X- rays, including the X-rays conducted in service. In support of his opinion, Dr. Girardi cited to references showing that degenerative disc disease and spondylosis of the lumbar spine were very common findings in the general population, and that the presence of such disorders did not establish that the low back pain was caused by the disorders because they were often asymptomatic. He also cited to references indicating that low back pain is a very common complaint in the general population, with many etiologies. Risk factors for low back pain include smoking, ethanol, inactivity or heavy work, being overweight, hip or knee disorders, and an altered gait, among others. Some professions, such as nurses and truck drivers, were more prone to develop back pain. Dr. Girardi disagreed with Dr. Bash's opinion for the following reasons: (1) there is no support in the literature for Dr. Bash's conclusion that the degenerative changes were advanced for the veteran's age, in that spondylosis and arthritis were very common findings at all ages; (2) Dr. Bash's reference to the disease being limited to one level was not relevant, in that L5-S1 is the most common site for such problems and it is generally a localized disease; (3) although there was no evidence of an intervening spine injury and the veteran entered service with a normal physical examination, he also left service with a normal examination and X-ray, and back pain is not always caused by an injury; (4) the veteran reported having had back pain during and since service, but there was no evidence of such in the records; (5) there is no record of an in-service back injury; and (6) it is not possible to conclude that the veteran's symptoms in service were consistent with the currently diagnosed degenerative changes, in that the medical literature shows that the source of back pain is difficult to identify and many individuals have degenerative changes without symptoms. Following review of Dr. Girardi's opinion, Dr. Bash provided a supplemental report in February 2002. He stated that he disagreed with Dr. Girardi's opinion for the following reasons: (1) Dr. Girardi did not address the multiple references in the service medical records to the veteran's musculoskeletal complaints, which had to be evaluated in terms of whether they as likely as not were due to a spine injury; (2) the negative X-ray study on the veteran's separation from service did not rule out the possibility that he had a spine injury, in that evidence of an injury may have been detected had a magnetic resonance image (MRI) been performed; (3) the veteran's back complaints pre-dated the work-related complaints documented in 1987; (4) Dr. Girardi had not reviewed the veteran's X-rays, nor was he qualified to review the X-rays, which Dr. Bash had in order to support his opinion that the degenerative changes were advanced for the veteran's age; (5) Dr. Girardi did not provide any medical literature in support of his opinion; and (6) it is unclear whether Dr. Girardi had access to the entire medical record, because he did not comment on Dr. McDevitt's opinion or have access to the pertinent X-rays. Duty to Assist The regulation pertaining to VA's duty to inform the veteran of the evidence needed to substantiate his claim and to assist him in developing the relevant evidence was revised following initiation of the veteran's claim. Duty to Assist, 66 Fed. Reg. 45,620 (Aug. 29, 2001) (to be codified at 38 C.F.R. § 3.159). The changes in the regulation are effective November 9, 2000, with the enactment of the VCAA, and apply to all claims filed on or after November 9, 2000, or filed previously but not yet final as of that date. Holliday v. Principi, 14 Vet. App. 282-83 (2001), mot. for recons. denied, 14 Vet. App. 327 (2001) (per curiam), motion for review en banc denied, No. 99-1788 (U.S. Vet. App. May 24, 2001) (per curiam) (en banc); VAOPGCPREC 11-00. Because the veteran appealed the July 1998 decision, it had not become final on November 9, 2000, and the provisions of the VCAA apply to his claim. According to the revised regulation, on receipt of a claim for benefits, VA will notify the veteran of the evidence that is necessary to substantiate the claim. VA will also inform the veteran which information and evidence, if any, that he is to provide and which information and evidence, if any, VA will attempt to obtain on his behalf. VA will also request that the veteran provide any evidence in his possession that pertains to the claim. VA will also make reasonable efforts to help the veteran obtain evidence necessary to substantiate the claim, including making efforts to obtain his service medical records, if relevant to the claim; other relevant records pertaining to service; VA medical records; and any other relevant records held by any Federal department or agency, State or local government, private medical care provider, current or former employer, or other non-Federal governmental source. In a claim for disability compensation, VA will provide a medical examination or obtain a medical opinion, which includes a review of the evidence of record, if VA determines it is necessary to decide the claim. Duty to Assist, 66 Fed. Reg. 45,620, 45,630 (Aug. 29, 2001) (to be codified at 38 C.F.R. § 3.159). The RO informed the veteran of the evidence needed to substantiate his claim in February and March 1998. The RO provided the veteran a statement of the case in September 1998 and a supplemental statement of the case in July 1999. In those documents the RO informed the veteran of the regulatory requirements for establishing service connection, and provided him the rationale for not granting service connection. The veteran's representative has been provided the claims file for review, and submitted additional evidence in support of the appeal. The veteran has also been provided copies of the evidence in the claims file. The RO notified the veteran that his case was being sent to the Board, and informed him that any additional evidence that he had should be submitted to the Board. Following the Court's remand, the Board informed the veteran's representative of his right to submit additional evidence and/or arguments in support of the appeal, and he did so. The Board finds, therefore, that VA has fulfilled its obligation to inform the veteran of the evidence needed to substantiate his claim. The Board notes that subsequent to the July 1999 supplemental statement of the case, the Board developed additional evidence that is relevant to the veteran's appeal. Under the regulation in effect prior to February 2002, this evidence would be referred to the RO for consideration in the first instance and the issuance of a supplemental statement of the case unless the veteran waived his right to such action. 38 C.F.R. § 20.1304 (2001). The veteran's representative has asked that the appeal be remanded to the RO for consideration of the newly submitted evidence. The regulation was revised, however, to allow the Board to consider evidence submitted to the Board, subsequent to the most recent supplemental statement of the case, without remanding the appeal to the RO. The changes to the regulations apply to all appeals pending at the Board on February 22, 2002. See Board of Veterans' Appeals: Obtaining Evidence and Curing Procedural Defects Without Remanding, 67 Fed. Reg. 3,099, 3,104 (Jan. 23, 2002). The veteran's representative was provided a copy of Dr. Girardi's opinion in accordance with 38 C.F.R. § 20.903 (as amended by 67 Fed. Reg. 3,099, 3,104 (Jan. 23, 2002), and submitted additional evidence in response. The Board finds, therefore, that remand of the case to the RO for consideration of the opinions of Drs. Girardi and Bash is not appropriate. The RO has obtained the service medical records, and to the extent possible the VA and private treatment records that have been identified by the veteran as relevant to the appeal. The Board notes that in January and October 1986 statements the veteran reported having received treatment for low back pain from the VAMC since 1978. The RO requested the treatment records from the VAMC back to June 1978, but no records prior to August 1981 were located. The Board concludes, therefore, that no additional records are available. The RO and the Board obtained medical opinions in order to assist the veteran in substantiating his claim. The veteran presented hearing testimony before the undersigned in June 2001. The veteran has not indicated the existence of any other evidence that is relevant to his appeal. Based on the extensive development that has been undertaken in this case, the Board concludes that all relevant information has been obtained for determining the merits of the veteran's claim and that no reasonable possibility exists that any further assistance would aid the veteran in substantiating the claim. Wensch v. Principi, 15 Vet. App. 362, 368 (2001). Analysis Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131. 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303. Where a veteran served for 90 days in active service, and arthritis develops to a degree of 10 percent or more within one year from the date of separation from service, such disease may be service connected even though there is no evidence of such disease in service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical or, in some circumstances, lay evidence of the incurrence or aggravation of a disease or injury in service or during the presumptive period; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Once the evidence is assembled, the Board is responsible for determining whether the preponderance of the evidence is against the claim. If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. 38 U.S.C.A. § 5107 (West 1991 & Supp. 2001); Ortiz v. Principi, 274 F.3d 1361, 1365-66 (Fed. Cir. 2001); 38 C.F.R. § 3.102 (as amended by 66 Fed. Reg. 45,620, 45,630 (Aug. 29, 2001)). The medical evidence shows that the veteran's low back complaints were diagnosed in May 1997 as spondylolysis of L5- S1 and disc disease at L5-S1. His claim is, therefore, supported by medical evidence of a current diagnosis of disability. For the reasons that will be explained below, however, the Board finds that the evidence does not establish the occurrence of a related disease or injury in service, or a nexus between the currently diagnosed disorder and an in- service disease or injury. Hickson, 12 Vet. App. at 253. The veteran does not contend that his claim is related in any way to active duty for training in 1976. The service medical records for his period of active service, from March 1977 to June 1978, are silent for any complaints or clinical findings that were attributed at the time to a low back disease or injury. Although the January 1978 request for an X-ray study indicates that the clinical history consisted of hip and low back pain, the remaining service medical records attribute the pain to the hips, not the back. The X-ray study of the spine was shown to be normal, and examination of the spine on separation from service in May 1978 revealed no abnormalities. The veteran has stated that he experienced back pain during service, and asserted that the complaints pertaining to the hips that were documented during service actually resulted from a back injury. Although the veteran as a lay person is competent to provide evidence of observable symptoms, he is not competent to associate those symptoms with a medical disorder. Savage v. Gober, 10 Vet. App. 488, 496 (1997). The service medical records show that his pain complaints were assessed as a hip disorder, not a low back disorder. The veteran's assertions are not, therefore, probative of having incurred a back injury or disease in service. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Dr. Bash found that the complaints documented during service related to a back injury, but that opinion was based on the veteran's reported history of a back injury when the wall locker fell on him. Although Dr. Bash stated that his opinion was based on review of the medical evidence, that evidence does not document any back injury during service. The service medical records indicate that the veteran incurred an abrasion to the right leg as a result of the fall, but they do not make any reference to him having complained of back pain or having incurred a back injury. Thus, Dr. Bash's opinion is not probative of the veteran having incurred a back injury in service. See Godfrey v. Brown, 8 Vet. App. 113, 121 (1995) (a medical opinion that is based on the veteran's recitation of medical and service history, and not his documented history, is not probative). Dr. Bash also found that the evidence of the veteran having been provided an X-ray study of the spine in January 1978 was evidence of him having symptoms of a back injury. The contemporaneous records indicate, however, that the physician in January 1978 requested an X-ray study because of the veteran's complaints pertaining to the hip; no complaints specific to the low back were then recorded, nor were any spinal abnormalities found on examination. In addition, the X-ray did not reveal any abnormalities in the spine. Although Dr. Bash has opined that the X-ray study is not determinant because spinal abnormalities are more accurately determined by an MRI, the X-ray study is, nonetheless, probative evidence of whether the veteran incurred a back injury in service. Dr. Bash's implication that had an MRI been conducted at that time the degenerative changes may have been found is speculative and not supported by any clinical evidence. For this additional reason, Dr. Bash's opinion is not probative of the veteran having incurred a back injury in service. See Beausoleil v. Brown, 8 Vet. App. 459, 465 (1996) (an opinion indicating only the possibility of a medical relationship is not probative of service connection). Drs. McDevitt and Girardi both reviewed the service medical records and concluded that there was no evidence of the veteran having incurred a back injury in service. Because such finding was based on review of the service medical records, and not merely the veteran's reported history, it is highly probative. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (an opinion that is based on review of the medical evidence is more probative than an opinion based on the veteran's reported history). For these reasons the Board finds that a back injury or disease was not incurred in service. Nor was a chronic disease compensably manifested during the one-year presumptive period following the veteran's separation from active service. The veteran made no reference to any back complaints when he filed for compensation benefits in June 1978 and June 1981. His spouse stated in 1981 that he began complaining of back pain in August 1978, two months after he was separated from service, when he was performing heavy lifting. There is no medical documentation of the veteran's back complaints prior to June 1980, when he reported having been working in construction. Numerous physical examinations and X-ray studies from June 1980 to May 1997 did not confirm any objective evidence of back pathology, and multiple X-ray studies were shown to be normal. The Board finds, therefore, that the veteran's assertion of having experienced low back pain since he was in service is not credible. See Madden v. Gober, 123 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board is entitled to discount the credibility of the evidence in light of its own inherent characteristics and its relationship to other items of evidence). Dr. Nelson stated in 1986, in response to the veteran's request for assistance in establishing service connection for arthritis of the spine, that the veteran had not developed arthritis of the spine while in service. Drs. McDevitt and Girardi found, based on review of the medical evidence of record, and not the veteran's reported history, that there was no relationship between the currently diagnosed back disorder and the veteran's military service. The latter opinions were provided by orthopedic surgeons and were supported by analysis of the medical evidence of record, and are highly probative. See Struck v. Brown, 9 Vet. App. 145, 154-155 (1996) (the Board is entitled to weigh the credibility and probative value of the evidence as long as a rational basis is given for doing so). Although Dr. Bash found that the disorder that was diagnosed in May 1997 was related to a back injury that occurred in service, that opinion is not probative because it was based on the veteran's reported history of having incurred such a back injury, which is not supported by the contemporaneous evidence. See Reonal v. Brown, 5 Vet. App. 458 (1993) (an opinion based on an inaccurate factual premise has no probative value). In addition to the veteran's report of having back pain during and since service, Dr. Bash attributed the disorder diagnosed in May 1997 to service because the degenerative changes were more advanced than he would expect for a man of the veteran's age. That assessment does not, however, take into account the veteran's long history of heavy labor, and is only speculative in finding that the disorder is due to an injury that occurred in service, rather than following service. Dr. Bash also relied on the arthritis being isolated to a single level, and not representing a systemic process. Dr. Bash's opinion may be relevant in determining whether the degenerative changes are due to trauma, but his finding is not probative of whether that trauma occurred during service . He found that there was no evidence of any intervening spine injury, but did not consider the fact that there was no evidence of a spine injury in service. He also found that the in-service diagnosis of Perthes' disease was inaccurate because X-ray studies of the hips were normal. The service medical records show, however, that although the veteran's complaints were initially assessed as Perthes' disease, the veteran's physician determined that there was no evidence of Perthes' disease following the X-ray and changed the diagnosis to arthralgia of the hips of unknown cause. Dr. Bash also cited to medical literature indicating that injuries to the spine early in life often lead to degenerative changes later in life, but that finding is not probative of whether "early in life" in this case means during service or following separation. Dr. Bash found fault with Dr. McDevitt's opinion because Dr. McDevitt did not take a patient history prior to rendering his opinion. Dr. McDevitt was asked to base his opinion on the medical evidence of record, and the veteran's reported history cannot be relied upon in evaluating a nexus to service. Dr. Bash stated that Dr. McDevitt had not reviewed the veteran's X-rays, which clearly showed L5-S1 disease. The determinative issue, however, is not whether the veteran currently has a spine disorder; the issue is whether that disorder is related to service. Although Dr. Bash indicated that he had reviewed the actual radiograph films, there are no such films in the claims file and Dr. McDevitt referred to the reports of the X-ray studies that are of record. Dr. McDevitt did not state that the veteran's current back disorder was due to Perthes' disease; he referenced the May 1997 X-ray findings of back pathology in finding that the currently diagnosed disorder was not related to service. Although Dr. McDevitt did not cite to any literature in support of his opinion, he was asked to provide the opinion based on his expertise as an orthopedic surgeon, and apparently found that reference to medical literature was not necessary in order to render his opinion. Dr. Bash disagreed with Dr. Girardi's opinion because Dr. Girardi did not address the multiple references in the service medical records to the veteran's musculoskeletal complaints in terms of whether they were due to a spine injury. In requesting the medical opinion, however, Dr. Girardi was asked to determine whether there was any objective evidence of a back injury in service. The veteran's claims of having incurred such an injury cannot be relied on in making that finding. Godfrey, 8 Vet. App. at 121. The contemporaneous evidence, which is more probative than the veteran's current assertions, do not document such an injury. See Curry v. Brown, 7 Vet. App. 59, 68 (1994). Dr. Bash found that the negative X-ray study on the veteran's separation from service, which Dr. Girardi referenced in his opinion, did not rule out the possibility that he had a spine injury because an MRI was not conducted. Dr. Girardi had been asked, however, to provide an opinion that was based on the evidence of record and, as previously stated, any assumption regarding what may have been found had an MRI been performed is speculative and not probative. Beausoleil, 8 Vet. App. at 465. Dr. Bash also noted that the veteran's back complaints pre-dated the work-related complaints documented in 1987. The evidence shows, however, that his work-related complaints were documented prior to 1987, including the statement by his spouse regarding his complaints in 1978 and the reference by Dr. Nelson to his complaints in June 1980. Dr. Bash found that Dr. Girardi's opinion was defective because he had not reviewed the actual radiographs and was unqualified to read the radiographs. As previously stated, whether the radiographs, which are not in file, showed that the degenerative changes were advanced for the veteran's age is not relevant in finding whether those changes are due to an injury in service or following service. It is unclear to the Board from Dr. Bash's opinion on what basis he determined that an orthopedic surgeon who specializes in spinal surgery is unqualified to read an X-ray film of the spine. Dr. Bash stated that Dr. Girardi did not provide any medical literature in support of his opinion, but in fact he referenced six different treatises in finding that the current back disorder was not related to service. Dr. Girardi based his opinion on the medical evidence of record, as he stated in the report, and he was not asked to comment on Dr. McDevitt's opinion. For these reasons the Board finds that Dr. Bash's comments regarding the validity of the opinions of Drs. McDevitt and Girardi are without merit, that the opinions of Drs. McDevitt and Girardi are more probative than that of Dr. Bash, and that the veteran's currently diagnosed back disorder is unrelated to an in-service disease or injury. The Board has determined, therefore, that the preponderance of the evidence is against the claim of entitlement to service connection for a low back disorder. The benefit-of-the-doubt rule is inapplicable because the doctrine only applies where there is an approximate balance of positive and negative balance. Ferguson v. Principi, No. 01-7012 (Fed. Cir. Dec. 4, 2001). ORDER The claim of entitlement to service connection for a low back disorder is denied. Charles E. Hogeboom Member, Board of Veterans' Appeals IMPORTANT NOTICE: The attached VA Form 4597 that tells you what steps you can take if you disagree with our decision. The Board is in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.