Citation Nr: 1002482 Decision Date: 01/14/10 Archive Date: 01/22/10 DOCKET NO. 06-14 787 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to service connection for limb girdle muscular dystrophy. REPRESENTATION Appellant represented by: John Steven Berry, Attorney ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran had active military service from December 1969 to March 1972. This matter comes back before the Board of Veterans' Appeals (Board) on Remand from the United States Court of Appeals for Veterans Claims regarding a Board decision rendered in February 2009. This matter was originally on appeal from an October 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. FINDING OF FACT The Veteran's limb girdle muscular dystrophy is a congenital disease, it existed prior to service, and it did not progress beyond its natural rate during service. CONCLUSION OF LAW Limb girdle muscular dystrophy preexisted service and was not aggravated by service. 38 U.S.C.A. §§ 1110 (West 2002); 38 C.F.R. §§ 3.303, 4.9 (2009). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). I. Veterans Claims Assistance Act of 2000 As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (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 & Supp. 2008); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. With respect to service connection claims, the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA has met all statutory and regulatory notice and duty to assist provisions. Letters dated in June 2005 and March 2006 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 6 Vet. App. at 183, Dingess, 19 Vet. App. at 473. Together, the letters informed the appellant of what evidence was required to substantiate the claim and of the appellant's and VA's respective duties for obtaining evidence, as well as how VA determines disability ratings and effective dates. In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must request that the claimant provide any evidence in his possession that pertains to the claim based upon 38 C.F.R. § 3.159(b). The requirement of requesting that the claimant provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule revising 38 C.F.R. § 3.159(b) to rescind fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. However, although this notice is no longer required, the Board notes that the Veteran was aware that it was ultimately his responsibility to give VA any evidence pertaining to the claim. The June 2005 letter told him to provide any relevant evidence in his possession. See Pelegrini, 18 Vet. App. at 120. The Veteran's service treatment records, VA medical treatment records, Social Security Administration (SSA) records, and identified private medical records have been obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that any additional evidence, relevant to the issues decided herein, is available and not part of the claims file. A medical expert opinion was also obtained in November 2008 which addressed whether the Veteran's limb girdle muscular dystrophy increased in severity during his active duty service in conjunction with a review of the claims file. The November 2008 expert medical opinion is adequate; and thus, the medical evidence of record is adequate upon which to base a decision. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). II. Service Connection The Veteran seeks service connection for limb girdle muscular dystrophy. Applicable law provides that service connection will be granted if it is shown that the Veteran suffers from a disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Initially the Board notes that in the Joint Motion for Partial Remand dated in July 2009, the parties agreed that the Board did not discuss the Veteran's condition in terms of a disease or defect, that it was not clear from the Board decision whether the Board found preexistence based on the nature of the disorder or the finding on the service entrance examination report, and that the Board did not adequately discuss the nature of the Veteran's reported congenital disorder as well as the applicability of the presumption of soundness to the Veteran's case. The Board first addresses more clearly whether the Veteran's limb girdle muscular dystrophy is a congenital disease or a congenital defect. Muscular dystrophy is defined as a group of genetic degenerative myopathies (disease of the muscle) characterized by weakness and atrophy of muscle without involvement of the nervous system. Limb-girdle muscular dystrophy is defined as a slowly progressive form of muscular dystrophy affecting either sex and beginning usually in childhood, but sometimes in maturity or later; it is characterized by weakness and wasting in the pelvic girdle or shoulder girdle. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 520, 1094 (28th Ed. 1994). Thus, based on Dorland's definition, the Board finds that the Veteran's limb girdle muscular dystrophy is a congenital disease. A Veteran will be considered to have been in sound condition when examined, accepted and enrolled in service, except as to defects, infirmities, or disorders noted at entrance into service, or where evidence or medical judgment is such as to warrant a finding that an injury or disease existed prior thereto. 38 U.S.C.A. §§ 1111, 1110. Clear and unmistakable evidence that the disability existed prior to service and was not aggravated by service will rebut the presumption of soundness. VAOPGCPREC 3-2003 (July 16, 2003). A pre-existing disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2009). VA's General Counsel has determined that service connection may be granted for diseases (but not defects) of congenital, developmental or familial origin if the evidence as a whole shows that the manifestations of the disease in service constituted "aggravation" of the disease within the meaning of applicable VA regulations. VAOPGCPREC 82-90 (July 18, 1990). Moreover, diseases of hereditary origin can be considered incurred, rather than aggravated, in service "if their symptomatology did not manifest itself until after entry on duty." VAOPGCPREC 67-90 (July 18, 1990). In this case, the Veteran's service treatment records indicate that on the clinical examination for entrance into service in December 1969, the Veteran's upper extremities were evaluated as abnormal. The abnormality was noted to be that the Veteran couldn't hold his arms above his head without holding his hands together. The examiner noted that there was no apparent loss of muscle strength or atrophy and assigned a U2 profile upon enlistment. This assignment of "U" signifies upper extremities and the assignment of "2" signifies "some limitations." See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992) (observing that the "PULHES" profile reflects the overall physical and psychiatric condition of the Veteran on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect that is below the level of medical fitness for retention in the military service). See generally Hanson v. Derwinski, 1 Vet. App. 512, 514 (1991), for an explanation of the military medical profile system. In a December 2005 letter, Dr. R.A.C. stated that he had reviewed a Report of Medical Examination dated December 18, 1969 and that the examination at that time revealed "shoulders-cannot hold arms above head without holding hands together-no apparent loss of muscle strength or atrophy". Dr. R.A.C. also stated that the Veteran told him that at the time of the evaluation, he had lab work done that was abnormal but he did not have any of those results nor did he know what laboratory testing was abnormal. Dr. R.A.C. stated that it was his opinion that the Veteran had clinical evidence of his limb girdle muscular dystrophy back in 1969 when he underwent his physical examination on enlistment into the Navy. In an August 2006 letter, Dr. R.A.C. opined that there was no doubt that the Veteran was suffering from the early stages of muscular dystrophy at the time of his induction physical. In a February 2007 letter, Dr. G.P., of the MDA Clinic, stated that after reviewing the Veteran's Navy records from December 1969, in which there was a mention of a difficulty with proximal arm weakness at that time, these clinical features would certainly be consistent with the Veteran's underlying muscular dystrophy disease. Dr. G.P. also stated that it was his medical opinion that the Veteran's muscular dystrophy existed at that time. As there are no qualified medical opinions to the contrary, the Board accepts the medical opinions of record as clear and unmistakable evidence that the Veteran's limb girdle muscular dystrophy is congenital and existed prior to service. As discussed hereinafter there is also clear and unmistakable evidence that limb girdle muscular dystrophy was not aggravated during service. Thus, entitlement to service- connection should turn on the question of whether manifestations of the disease in service constitute "aggravation" of the condition. VAOPGCPREC 82-90 (July 18, 1990). Where an hereditary disease has manifested some symptoms prior to entry on duty, it may be found to have been aggravated during service if it progresses during service at a greater rate than normally expected according to accepted medical authority. Id. There is no aggravation of a preexisting disease or injury if the condition underwent no increase in severity during service on the basis of all of the evidence of record pertinent to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). Intermittent or temporary flare-ups during service of a preexisting injury or disease do not constitute aggravation; rather, the underlying condition must have worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The service treatment records are absent complaints or findings of any muscle weakness during the Veteran's time in service. On the clinical examination in January 1970 and on the clinical examination for separation from service in March 1972, the Veteran's upper and lower extremities were evaluated as normal. The Veteran's post-service medical records indicate that the Veteran was diagnosed in 1978 with limb girdle muscular dystrophy. The record indicates that the Veteran was hospitalized for a few days in May 1978 with complaints of increasing weakness of his upper arms bilaterally over the previous three years and progressively worse over the previous year in particular. A March 1979 letter authored by Dr. R.A.C. indicates that there appeared to be a slight increase in proximal upper extremity weakness. Dr. R.A.C. noted that the Veteran continued to work quite hard in a job which required him to do a tremendous amount of repetitive lifting using the upper extremities and opined that that type of work was contraindicated in view of the fact that it may have precipitated some of his deterioration. A July 1981 letter authored by Dr. R.A.C. indicates that the Veteran's muscular dystrophy had recently rapidly progressed, especially with respect to a sudden increase in weakness in the lower extremities. In March 1982, the Veteran underwent evaluation at the Mayo Clinic. A March 1982 letter from Dr. D.W.M. of the Mayo Clinic stated that it was quite clear that the Veteran was suffering from a muscular dystrophy which might best be classified as a limb girdle type and he assumed that it was being inherited as a recessive. Dr. D.W.M. stated that it would be his advice that the Veteran should continue working, that it was obvious that he did have some limitations, but that in his experience this particular form of dystrophy was very slow and most patients were able to compensate adequately for it for many, many years. In April 1983, the Veteran was having increased numbness in his hands. In March 1984, the Veteran had had a small increase in his bilateral foot drop and complained of aches and pains after a full day's work. In January 1988, the Veteran underwent a neurological re- examination. It was noted that the Veteran continued to work at the packing house doing stock work and running machinery. The Veteran was having increasing lower back pain because of the amount of lifting that he had to do. Upon examination, there was severe wasting of the biceps, triceps, and supra and infraspinatus. He had moderate wasting of the anterior tibialis bilaterally and it was worse on the right with a moderate foot drop on the right and mild foot drop on the left. On a disability report completed by the Veteran in January 1988, he noted that his condition first bothered him in April 1978. SSA records indicate that the Veteran was considered disabled for SSA purposes on January 25, 1988 with a primary diagnosis of muscular dystrophy and a secondary diagnosis of lumbosacral strain. In a June 1988 letter, Dr. R.A.C. stated that the Veteran's disorder had been progressive and that because of this, it was his feeling that the Veteran could no longer work. Dr. R.A.C. noted that the Veteran's weakness had progressed to the point that he required the use of all accessory muscles to do any type of bending, walking, and lifting and this was continuing to cause him increasing problems with discomfort. Dr. R.A.C. noted that the condition was progressive and not reversible, that it would be affecting the Veteran for the rest of his life, and that there was no known treatment for the disorder. In a December 2005 letter, Dr. R.A.C. stated that the Veteran had had a continued progressive course of difficulties to the point that he was able to ambulate to some degree with the use of a cane but spent a significant amount of time in a wheelchair and that he had been unable to work for a number of years because of his disorder. As noted above, Dr. R.A.C. stated that it was his opinion that the Veteran had clinical evidence of his limb girdle muscular dystrophy back in 1969 when he underwent his physical examination on enlistment into the Navy. Dr. R.A.C. noted that patients with this disorder early on can function but any type of strenuous activity including lifting, pushing, climbing, etc., could cause significant fatigue because of the accessory muscles needed to do these functions. Dr. R.A.C. opined that the Veteran's work on a submarine, assuming that it required a fair amount of physical activity, would have undoubtedly caused him fatigue which, if unable to gain adequate rest in between these physical activities, would have caused significant problems with his overall functioning. In an August 2006 letter, Dr. R.A.C. opined that it was much more likely than not any type of physical activity that the Veteran was engaged in during his time in service would have aggravated his condition. In a March 2007 Medical Evaluation Report, Dr. C.N.B., opined that the Veteran's dystrophy worsened during service according to the Veteran's February 2007 lay statement. Dr. C.N.B. also stated that it was his opinion that the Veteran's worsening upper limb function during service and following service represented an aggravation of his limb girdle dystrophy and that had he not been in service that his disease would have been less severe for the following reasons: (1) he entered service with inability to raise his arms, (2) he had progressive worsening of his arm function in service, (3) the extensive use of his arms in service likely lead to irreversible damage to his joint ligaments and joint surfaces because once these areas are damaged incomplete healing occurs, thus the Veteran would have likely avoided his rapid decline in function had he not had his service time physical experiences, (4) the opinion of Dr. R.A.C. supports this opinion, (5) the Veteran's lay statements are consistent with this opinion, (6) this opinion is supported by Dr. G.P.'s opinion that the Veteran's muscular dystrophy existed in 1969. Dr. C.N.B. summarized that the Veteran had his dystrophy during service time and that he had significant physical exertion of his arms during service, that the medical opinions contained in the file all support the concept that the Veteran's dystrophy was likely made worse during service time due to the over use syndrome, that none of the opinions stated that his disease was made better by the physical activity during service or that his service experiences were protective of further damage, and that his lay statements all state that his arm function worsened during service time. Dr. C.N.B. concluded that it was his opinion that the Veteran's dystrophy was likely aggravated during service due to his excessive physical activity as documented by his worsening limb function during service and the attached medical opinions. In October 2008, the Board requested a medical expert opinion as to whether the Veteran's muscular dystrophy was aggravated by the Veteran's military service and if so, if the worsening was beyond the natural progress of the disease. Dr. M.J.L. rendered the opinion that the documentation in the Veteran's claims file documented no unexpected progression during his service years. Dr. M.J.L. noted that at the Veteran's discharge physical, no problems were noted which suggested that a dramatic worsening occurred during the Veteran's military career. She also noted that this was not surprising given that the natural history of limb-girdle muscular dystrophy was usually of slow progression. Dr. M.J.L. noted that the claims file documents fairly typical progression over more than 30 years after service. The Veteran initially was only affected in his upper shoulder girdle area; later, it progressed to his hip area; and he ultimately developed foot drop and required ankle foot orthoses and most recently a wheelchair. Dr. M.J.L. stated that it was her opinion that the evidence does not show that the Veteran's muscular dystrophy was aggravated by his military service beyond what would be expected for the natural progress of limb-girdle muscular dystrophy. In a November 2005 written statement, the Veteran noted that in 1970 he had tingling and numbness in his legs and arms while climbing on ladders in submarine and that during his interior communications school, his hands would ache with numbness going up his arms when writing. The Veteran also noted that he had aches and fatigue in his arms, shoulders and legs during his time in the navy but just passed it off as being tired due to the extreme rigors of submarine service. In addition, in a February 2007 statement, the Veteran noted that in the course of his daily duties, he would climb up and down ladders, work on equipment above his head (which was difficult to raise his arms), and go down in the battery wells to clean the main storage batteries on his hands and knees. The Veteran stated that when his arms would ache and go numb there was no one to complain to because they did not have a corpsman or a medical department. He was in the seaman gang and electrical gang and stood look out and helm watches as well as working on electrical equipment. He also stated that he was the battle station bow planesman so that if they were at battle station for eight or ten hours, he kept the boat on the depth called out by the diving officer. The Veteran stated that he never had more than four to six hours of sleep a day for the one to three weeks he would be out to sea. He stated that he ate a minimum amount of food to keep from throwing up. The Veteran noted that it was always cold in the winter and hot in the summer. His arms would especially go numb in the winter. He also noted that when in shore, he carried on supplies by hand and repaired equipment. He was responsible for filling the 16 battery water tanks with distilled water by pulling a hose through the boat to the tanks. The constant wave action made him exhausted. He slept above a torpedo which was difficult for him to climb above. The Veteran also stated that in the second or third week of boot camp, the problem of lifting his arms became increasingly difficult and his company commander decided to put him in the color guard to complete boot camp without physical training. Further, in a December 2008, statement, the veteran notes that "Falling from a ladder while onboard the submarine in 1971 clearly shows my overall function being impacting, including upper arm weakness." In adjudicating a claim, the Board must assess the competence and credibility of the Veteran's statements. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board also has a duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Veteran is competent to give evidence about what he experienced in service such as the symptoms reported in his November 2005 statement. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). Competency, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Board acknowledges that it cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). However, such lack of contemporaneous evidence is for consideration in determining credibility. In this case, the Veteran's assertions of symptoms of limb girdle muscular dystrophy during service of tingling and numbness in his legs and arms while climbing on ladders in submarine, aching hands and numbness going up his arms when writing, and aching and fatigued arms, shoulders, and legs is contradicted by other evidence of record. With respect to the veteran's assertions that falling from a ladder in 1971 clearly shows that his overall functioning was impacted, including upper arm weakness, the Board acknowledges that the Veteran presented in June 1971 for treatment for a 3-inch laceration sustained while coming down a ladder. The veteran also presented in Jul 1971 for suture removal. However, there is no documentation with respect to any limitation of arm or leg functioning. As noted above, the relevant service treatment records on file are absent any complaints or findings of muscle aches, numbing, or weakness during the Veteran's time in the Navy. On the Report of Medical History completed in conjunction with a January 1970 physical examination, the Veteran specifically denied every having neuritis or any complaint that might have a muscular origin. The Board emphasizes that the Veteran served slight over two years without any documented contemporaneous complaints or treatment for weakness, numbness, or pain in his upper or lower extremities and he affirmatively reported no relevant complaints. In addition, a disability report completed and signed by the Veteran on January 28, 1988 stated that his condition first bothered him in April 1978. This document was signed under a statement which reads, "Knowing that anyone making a false statement or representation of a material fact for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal Law, I certify that the above statements are true." Further, the Veteran complained during a May 1978 hospitalization of increasing weakness of his upper arms bilaterally over the prior three years and progressively worse over the prior year in particular. As noted above, the Veteran was discharged from service in March 1972, and in May 1978, he reported increasing weakness in his upper arms from sometime in 1975. The Board notes that lay statements made when medical treatment was being rendered may be afforded greater probative value as these records were generated with a view towards ascertaining the Veteran's then-state of physical fitness, and as such, they are akin to statements of diagnosis and treatment and are of increased probative value. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that, although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). The Board notes that at no time prior to the date the Veteran filed his claim for compensation in May 2005 did he assert that he experienced any symptoms of his limb girdle muscular dystrophy during his time on active duty. The Board finds that self-interest is a factor that may be taken into consideration when determining credibility as to the Veteran's statements. See Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). As the record includes internal inconsistencies with respect to the timing of when the Veteran's muscular dystrophy symptoms first "bothered him" coupled with the lack of any contemporaneous medical records showing complaint of any upper or lower extremity problems during service, the Board finds that the Veteran's statements that he suffered from symptoms of his limb girdle muscular dystrophy during service are not credible. The Board notes that there is a difference of opinion among the medical professionals. In deciding whether the Veteran's muscular dystrophy was aggravated beyond the natural progression of the disease in service, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Evans v. West, 12 Vet. App. 22, 30 (1998). That responsibility is particularly onerous where medical opinions diverge. At the same time, the Board is mindful that it cannot make its own independent medical determinations and that there must be plausible reasons for favoring one medical opinion over another. Id. The Board notes that the opinion of Dr. G.P. only addresses the issue of whether the Veteran's muscular dystrophy was present at the time of his entrance physical. It does not address the issue of whether the pre-existing muscular dystrophy was aggravated by the Veteran's military service. Thus, this opinion is not probative of the current issue at hand. With respect to the remaining medical opinions of record, there are legitimate reasons for accepting the unfavorable medical opinion of Dr. M.J.L. over the opinions of Dr. R.A.C. and Dr. C.N.B. With regard to medical evidence, an assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. Indeed, the courts have provided guidance for weighing medical evidence. They have held, for example, that a post- service reference to injuries sustained in service, without a review of service medical records, is not competent medical evidence. Grover v. West, 12 Vet. App. 109, 112 (1999). Also, a medical opinion is inadequate when unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). In addition, a medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Thus, the weight to be accorded the various items of medical evidence in this case must be determined by the quality of the evidence and not necessarily by its quantity or source. As noted above, Dr. R.A.C. opined that the Veteran's work on a submarine would have undoubtedly caused him fatigue which, if unable to gain adequate rest in between these physical activities, would have caused significant problems with his overall functioning and that it was much more likely than not any type of physical activity that the Veteran was engaged in during his time in service would have aggravated his condition. Dr. C.N.B. opined that the Veteran's dystrophy worsened during service according to his February 2007 lay statement. However, as noted above, the Board finds that the Veteran's February 2007 statement is not credible. As the Board has found that the Veteran's February 2007 statement is not credible, the Board also finds that an independent medical opinion based in no small part on the Veteran's February 2007 lay statement, is not probative. Reonal, 5 Vet. App. at 461. Both Dr. R.A.C.'s and Dr. C.N.B.'s opinions, unfortunately, fail to address the relevant service treatment records on file which document the normal evaluation for the Veteran's upper and lower extremity strength at separation as well as a gap of more than three years for complaint of any muscle weakness and a gap of more than five years for treatment, as well as the veteran's contemporaneous report of no problems prior to 1975. In comparison, all of these factors were considered by the VA medical expert. She reviewed the entire claims file, provided an opinion based on the medical evidence of record, and supplied a detailed rationale outlining the medical evidence that the Veteran's muscular dystrophy did not progress at an abnormally high rate during service. Thus, the 2008 VA medical opinion has been accorded very large probative weight. The Board finds it contradictory that in a March 1979 letter, after the Veteran demonstrated a slight increase in proximal upper extremity weakness, Dr. R.A.C. noted that the Veteran continued to work quite hard in a job which required him to do a tremendous amount of repetitive lifting using the upper extremities and opined that that type of work was contraindicated in view of the fact that it may have precipitated some of his deterioration. Yet, without the benefit of any clinical findings during service, Dr. R.A.C. found that it was much more likely than not that any type of physical activity that the Veteran was engaged it during his time in service would have aggravated his condition, especially in light of Dr. D.W.M.'s advice that the Veteran should continue working and that most patients were able to compensate adequately for it for many, many years. Further, Dr. R.A.C. does not provide any rationale for his opinions in light of the veteran's contemporaneous report, in 1978, that he first experienced problems in 1975. Therefore, Dr. R.A.C.'s opinions will be accorded very small probative weight. The Board also finds Dr. C.N.B.'s rationale for his opinion that had the Veteran not been in service, that his disease would have been less severe is inadequate. As noted above, Dr. C.N.B. based his opinion on the following reasons: (1) The Veteran entered service with inability to raise his arms, (2) he had progressive worsening of his arm function in service, (3) the extensive use of his arms in service likely lead to irreversible damage to his joint ligaments and joint surfaces because one these areas are damaged incomplete healing occurs, thus the Veteran would have likely avoided his rapid decline in function had he not had his service time physical experiences, (4) the opinion of Dr. R.A.C. supports this opinion, (5) the Veteran's lay statements are consistent with this opinion, (6) this opinion is supported by Dr. G.P.'s opinion that the Veteran's muscular dystrophy existed in 1969. The Board notes that a medical opinion is inadequate when unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). This is the case with Dr. C.N.B.'s opinion. It is not based on clinical evidence of any worsening in service, the veteran's current report has been found to be not credible as to symptoms during service, and contemporaneous treatment records indicate that the veteran reported no problem until 1975. Thus, Dr. C.N.B.'s opinion is of no probative weight. The Board finds that the Veteran's limb girdle muscular dystrophy is a congenital disease and that there is clear and unmistakable evidence that limb girdle muscular dystrophy preexisted the Veteran's military service. Further, based upon the above analysis and probative weights assigned, the Board finds that there is clear and unmistakable evidence that the Veteran's limb girdle muscular dystrophy did not undergo aggravation beyond that which would normally be expected according to accepted medical authority during service. Accordingly, since clear and unmistakable evidence shows that limb girdle muscular dystrophy preexisted service and was not aggravated therein, the preponderance of the evidence is against the claim and service connection for said disability is denied. ORDER Entitlement to service connection for limb girdle muscular dystrophy is denied. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs