Citation Nr: 1002829 Decision Date: 01/19/10 Archive Date: 02/01/10 DOCKET NO. 08-11 708 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUE Entitlement to service connection for a low back disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Katz, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1942 to January 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office in Wichita, Kansas (RO) and Board remand. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The evidence of record demonstrates that a low back disorder is not related to active duty service, and arthritis was not diagnosed within one year of service discharge. CONCLUSION OF LAW The Veteran's current low back disability was not incurred in or aggravated by active duty service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2009). REASONS AND BASES FOR FINDING AND CONCLUSION With respect to the Veteran's claim for entitlement to service connection for a low back disability, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2009). Prior to the initial adjudication of the Veteran's claim, a June 2007 letter satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, to include the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007); Sanders v. Nicholson, 487 F.3d. 881, 887 (Fed. Circ. 2007), rev'd on other grounds, Sanders v. Shinseki, 556 U.S. - (2009). Thus, the Board finds that the content requirements of the notice VA is to provide have been met. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records, his VA treatment records, and his identified private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board observes that the Veteran reported treatment for his low back disorder from various private physicians, including Dr. Lang, Dr. Silkman, Dr. Hartness, Dr. White, and Dr. Farmer, who he reported are now deceased. The Veteran also stated that he has been unable to obtain treatment records from these doctors. As the Veteran has indicated that those treatment records are not available, additional requests for such records would be futile. 38 C.F.R. § 3.159(c)(1). In addition, the Veteran was provided with a VA examination in August 2009 with regard to his claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159; see McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). The Veteran has not indicated that he found this examination to be inadequate. Moreover, the Board finds that the August 2009 examination was more than adequate, as it was based on a review of the Veteran's claims file, an interview with the Veteran, and a physical examination of the Veteran. Also, it provided supporting rationale for the conclusion that the issue of whether the Veteran's low back disability is related to service could not be determined without resorting to mere speculation, but that the Veteran's low back disability was most likely due to post-service injuries and occupations. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Finally, there is no indication in the record that additional evidence relevant to the issue being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 112. 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, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In various statements, the Veteran has alleged that he injured his low back during service. Specifically, he stated that, while in the process of deboarding his ship in the South Pacific theater with a full pack on and a rifle, he fell on and injured his back when his ship was accidentally hit by another ship. He contends that he has had low back pain since that time. In his September 2003 claim, the Veteran indicated that he had terrible pain in his back after he fell, and that his comrades helped him get to shore and into a foxhole for protection. He noted that he was able to move after a few hours, but that he was too busy to find medical help after he returned to headquarters, so he never reported to a medic. He also reported that he did not seek medical treatment because he did not want to be transferred to another "outfit." He stated that he found a chiropractor after discharge in 1946, and that he continues to have treatment for back pain to this day. In a March 2009 statement, he reported that he did not go to sick call when he injured his back during service because he did not want to be sent to a hospital for treatment and return to another "outfit." Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection for certain chronic diseases, including arthritis, will be presumed if they are manifest to a compensable degree within the year after active service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). In order to establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in- service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999). Historically, the Veteran served on active duty from January 1942 through January 1946. A January 1942 entrance examination reveals that there were no musculoskeletal defects. A January 1946 separation examination reflects that the Veteran incurred a right knee injury in April 1944. No other musculoskeletal defects were noted. The Veteran's service treatment records are negative for any complaints of or treatment for a low back disorder. A January 1947 VA examination did not reveal any complaints or diagnoses of a low back disorder. In fact, the Veteran denied any medical attention since service discharge. Unit history reports from the Veteran's unit from August 1944, in the form of an excerpt from Sergeant Diffenderffer's diary, reflect that a big Liberty ship swung around and hit the unit's ship that month, and that the side of the ship was damaged. The report also notes that some life rafts and other equipment were knocked down on the boat deck. Private treatment records from E. Davidson, D.C. for the period of October 2001 through April 2008 reveal numerous complaints of, and chiropractic treatment for, a low back disability. The first report of treatment for a low back disability was in November 2001. In March 2002, the Veteran complained of low back pain after getting off of a bicycle. A June 2002 treatment record reflects a diagnosis of L5-S1 disk swelling. In August 2002, the Veteran complained of low back pain and noted that, in July 2002, he missed a step coming down a ladder. Other August 2002 treatment records note the Veteran's complaints of low back pain after changing a flat tire. The diagnosis was lumbar and sacroiliac sprain after changing a tire. A September 2002 record notes a diagnosis of L5-S1 disk degeneration. In November 2002, the Veteran complained of low back pain after twisting the wrong way while on a ladder cutting tree branches. In December 2002, the Veteran complained of low back pain after missing a step while coming down off of a ladder. A January 2003 treatment record notes the Veteran's complaints of low back pain after stumbling while coming off of a ladder while taking Christmas decorations down. In February 2003, the Veteran complained of low back pain after he fell while tangled up in a dog leash. A July 2003 treatment record notes that the Veteran reported low back pain after riding a lawn mower. In November 2003, the Veteran complained of low back pain after raking leaves and cleaning gutters. A December 2003 treatment record notes the Veteran's complaints of low back pain after shoveling snow. A June 2004 treatment record from Dr. Davidson reflects the Veteran's complaints of low back pain after almost falling off of a ladder. In September 2004, the Veteran complained of low back pain after missing a step on a ladder. In December 2004, the Veteran noted low back pain after climbing a ladder to put up Christmas lights. In January 2005, the Veteran complained of low back pain after shoveling show and ice. In November 2005, the Veteran complained of low back pain after putting up Christmas decorations. A February 2006 treatment record notes the Veteran's complaints of low back pain after moving furniture up into the attic. In August 2006, the Veteran complained of low back pain after falling over a two-wheel cart. In October 2006, the Veteran noted low back pain after tripping over a cord. In July 2007, the Veteran reported low back pain after tripping on a sidewalk. An August 2007 treatment record notes the Veteran's complaints of low back pain after stumbling on a curb. Private medical treatment records from D. Gillenwater, M.D. for the period of February 2003 through July 2003 reveal that the Veteran underwent two epidural steroid injections in his lumbar spine. February 2003 treatment records note that the Veteran reported pain in the midline of the low back and near the mid-lumbar region during the prior year. The Veteran reported a history of longstanding intermittent back pain ever since his service in the military. The diagnosis was degenerative lumbar disk disease with probable nerve impingement causing low back pain. July 2003 treatment records also show a diagnosis of degenerative lumbar disk disease with probable nerve impingement causing low back pain. VA treatment records from December 2002 through December 2004 reveal two complaints of low back pain. In November 2003, the Veteran complained of low back pain and indicated that he used Tylenol as needed. In March 2004, the Veteran complained of low back pain. He reported that he injured his back during service when he was knocked down after another ship struck his ship. He noted that he has had pain in his back ever since that time. He indicated that he did not undergo an x-ray during service, and that the medics told him that he had an injury "that will probably get worse in later years." He stated that he had periodic chiropractic treatments over the years, which gave him relief. The VA treatment record reflects that x-rays of the lumbar spine showed "very little in the way of degenerative change or spondylosis for his age." The diagnosis was chronic low back pain. A March 2004 letter from Dr. Davidson notes that the Veteran was treated 81 times for his low back disorder during the year of 2003. An October 2004 letter from Dr. Davidson reflects that the Veteran was treated 123 times for a lumbar spine disorder since January 2003. In a June 2005 letter, Dr. Davidson reported that he treated the Veteran for lumbar spinal problems since October 2001, and that his condition and symptoms required chiropractic care often to control the joint pain and symptoms. In a June 2006 letter, Dr. Davidson noted that the Veteran was treated 75 times from January 2005 through December 2005, and that treatment consisted of chiropractive manipulative treatment. In a February 2009 letter, Dr. Davidson reported that the Veteran was treated 92 times during the time period of January 2008 through December 2008. A January 2005 private treatment record from M. Baig, M.D. notes the Veteran's complaints of aching pain in the lumbar region of his back since 1944. The Veteran stated that he was a retired meat cutter and farmer by profession. He also reported that, during service, his ship was hit by another ship which made him lose his balance and fall on his back while wearing a backpack. He noted that, since then, he has had pain in the lumbar region and the thoracic area, and that he has been treated by a chiropractor. He stated that his symptoms had a sudden onset in 1944 associated with the accident. The Veteran complained of pain every day, which was worse towards the end of the day. He noted that standing, bending forward, and bending backward made the pain worse, and that bed rest, heat, and wearing a corset relieved the pain. He reported difficulty walking, and pain which was a 6 on a 1 to 10 scale. Physical examination showed the spine to be well-balanced over the pelvis. There was tenderness on percussion over the thoracolumbar junction. Straight leg raises were 40 degrees on the left and 60 degrees on the right. A Lasegue's test was positive on the left. A Jugular compression test, femoral stretch test, and Patrick's test were negative. Motor strength was 4/5 bilaterally in the quadriceps, and a sensory examination showed hypesthesia in the foot. An x-ray of the lumbar spine revealed interbody fusion between L1 and L2, which was suggestive of an old injury; mild degenerative changes in the rest of the lumbar spine; and diminished joint spaces in the medial compartment of both hips suggestive of degeneration arthritis. The diagnosis was L4 radiculopathy. A March 2005 computed tomography scan (CT) of the lumbar spine revealed disc degeneration at L5-S1 with moderate facet disease; mild central spinal stenosis of L4-L5 with facet disease; and mild bulging of the disc and annulus at L2-L3 and L3-L4 without focal protrusion or spinal stenosis. In a June 2005 letter, Dr. Baig reported that the Veteran had back pain ever since an injury that occurred during World War II, and that the Veteran was involved in a ship accident where one ship struck his ship, causing him to fall down on his back while wearing a backpack. Dr. Baig further noted that, since that time, the Veteran has had severe back pain that has plagued him his whole life, and that the Veteran had fusion of L1-L2 and that he developed severe pain arthritis secondary to the 1944 in-service injury. Dr. Baig stated that "[i]t appears that this patient has a service-connected injury ever since 1944," that he had continuance of back pain ever since that time, and that his pain and problems have progressively worsened over time. A November 2006 private medical treatment record from A. Manguoglu, M.D. notes the Veteran's complaints of chronic back pain ever since an injury during World War II which required extensive chiropractic treatment over the years. On examination, reflexes in the lower extremities were absent. Straight leg raising was negative bilaterally. There was diminished pinprick sensation in the distal lower extremities, most likely due to his diabetic peripheral neuropathy. There was no obvious atrophy or fasciculations and nothing focal on neurological examination. The diagnosis was chronic back pain with a right-sided radicular component with an underlying moderate degree of lumbar spinal stenosis in the lower lumbar region of L4-L5, L5-S1 disc protrusion. Back surgery was not recommended. A February 2007 treatment record from F. Smith, D.O. notes the Veteran's complaints of back pain since World War II when he was injured when another ship struck his ship. Dr. Smith indicated that the records that the Veteran had were reviewed. Physical examination showed absent reflexes at the ankles and trace at the knees. Straight leg raising showed tight hamstrings and pulling up in the back with standing. Forward bending was very good, but backward bending caused pain. The diagnosis was lumbar spondylosis with spinal stenosis. Dr. Smith noted that the symptoms seemed to be more indicative of a facet type of problem rather than radiculopathy or discogenic pain. In August 2009, pursuant to Board remand, the Veteran underwent a VA spine examination. The report notes his complaints of low back pain, which began in August 1944. The Veteran stated that he fell on his back while wearing a heavy pack when another ship ran into his ship during service. He reported that his back pain has gotten progressively worse, and described the pain as sharp spasms which were moderate. He complained of frequent acute episodes of back pain 12 days per month, and that he sought treatment from a chiropractor, but did not have physician prescribed bed rest. He also noted flare-ups which were moderately severe and an 8.5 on a 1 to 10 scale. He reported that the flare-ups occurred every day in the morning, and that they lasted for most of the day. Precipitating factors included any activity or standing, and alleviating factors included medication, rest, and ice. The Veteran noted significant additional limitation of motion or functional impairment during the flare-ups. The Veteran also complained of morning stiffness, constant fatigue, frequent spasms, back weakness, decreased motion, numbness, paresthesias and weakness in the anterior right thigh. He denied any bladder complaints, except for nocturia due to prostate size. He reported bowel complaints including constipation due to medication, but not due to his back disorder. He also noted a 10-year history of erectile dysfunction due to age, hypertension, depression, and diabetes mellitus. The VA examiner noted that the Veteran ambulated with a cane for support due to bilateral knee replacements and that he used an over-the-counter back support. The examiner reported that the Veteran could walk one block, and that he was unsteady due to age and his knees. The Veteran had a history of four falls in the past four months. The VA examiner indicated that the Veteran reported a back injury in August 1944 when he fell backwards on his pack and denied other injuries; however, the VA examiner noted that the post-service evidence showed multiple injuries since military service. The Veteran could only walk four blocks due to back pain, but he was independent for eating, grooming, toileting, and dressing. He used handrails in the shower. The Veteran stated that he retired in 1978, but that he worked as a meat cutter since 1946 and that he farmed occasionally. Physical examination showed a mild thoracolumbar scoliosis of 10 degrees. The limbs were equal in appearance with no atrophy. Posture was slightly leaning forward, and gait was antalgic and unsure due to the knees. The position of the head was neutral, and curvatures of the spine were intact. The Veteran's back was symmetrical in appearance, and there were no functional limitations on standing and walking. Range of motion revealed forward flexion to 20 degrees, extension to 0 degrees, right and left lateral flexion to 10 degrees, left lateral rotation to 10 degrees, and right lateral rotation to 0 degrees. There was objective evidence of pain at rest, additional pain on motion, and on attempting repetitive use. There was no spasm, moderate weakness, tenderness over the lumbar spinous processes, and no atrophy or guarding. There was localized tenderness with preserved spinal contour and normal gait. There was not muscle spasm or guarding severe enough to result in an abnormal gait or an abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. There was no ankylosis or abnormality of the musculature of the back. Sensory examination showed sensation to be intact to light touch and pinprick in the bilateral lower extremities. Motor strength was 5/5 in the left extremity and 4/5 in the right extremity. There was no atrophy. Circumferential measurements were equal in the lower extremities. Tone was normal. Deep tendon reflexes were 2+ and normal. Cutaneous reflexes were intact, and there were no pathologic reflexes. Lasegue's sign and straight leg raises were negative, and a Waddell's test was negative. There was no evidence of intervertebral disc syndrome. X-rays of the lumbar spine showed no acute fracture and preserved vertebral body heights. At the L5-S1 level, there was mild spondylolisthesis with disc space narrowing, endplate of sclerosis and vacuum phenomena. There was mild disc space narrowing at T12-L1 and L1-L2, and there were small marginal osteophytes arising from the vertebral bodies. The diagnosis was degenerative osteoarthritis and disc disease of the lumbar spine. After a thorough review and discussion of the evidence in the Veteran's claims file, an interview of the Veteran, and a physical examination of the Veteran, the VA examiner found that he could not state that the Veteran's reported in- service injury caused his current low back disorder without resort to speculation. The examiner explained that the Veteran's advanced age and arthritic changes would be expected to be present in his spine in any case. In addition, the VA examiner noted that, over the years, the Veteran was a very active person with 19 documented injuries to his spine between May 2003 and August 2007. The VA examiner stated that it was "hard to state that his single injury falling back on his pack in 1944 caused his current back condition when after service he was in two professions which required physical back labor and there is evidence of many injuries to his back over the years." Ultimately, the VA examiner concluded that "due to his occupations after service with documented multiple injuries and also his age being a factor the his [sic] current condition is most likely due to post service injuries and occupations." After a thorough review of the evidence of record, the Board concludes that service connection for a low back disorder is not warranted. Initially, the Board observes that the medical evidence reflects diagnoses of a current low back disorder. Degmetich v. Brown, 104 F.3d 1328, 1333 (Fed. Cir. 1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). There is no evidence that arthritis was diagnosed within one year of service discharge. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. There is evidence that the Veteran injured his low back during active duty service. Although the Veteran's service treatment records are silent as to any complaints of or treatment for a low back disorder during service, the Veteran provided competent and credible statements that he injured his low back during service when he fell as a result of another ship hitting his ship in 1944. See Hickson, 12 Vet. App. at 253 (holding that service connection requires medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (2006) (noting that the Board must determine whether lay evidence is credible due to possible bias, conflicting statements, and the lack of contemporaneous medical evidence, although that alone may not bar a claim for service connection); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (holding that a lay witness is competent to testify to that which the witness has actually observed and is within the realm of his personal knowledge). Specifically, the available evidence of record corroborates the Veteran's statements that another ship struck his ship in August 1944. A history of the Veteran's company (from another sergeant's diary) notes that, in August 1944, the Veteran's ship was struck by another ship, and the collision caused life rafts and equipment to be knocked down. Thus, the Board accepts the Veteran's lay statements as credible evidence that he injured his low back during service. However, the competent and probative medical evidence of record does not support a nexus between the Veteran's current low back disorder and his active duty service. Hickson, 12 Vet. App. at 253 (holding that service connection requires medical evidence of a nexus between the claimed in- service disease or injury and the current disability); see also Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board must assess the credibility and probative value of the medical evidence in the record). Although Dr. Baig reported in January 2005 that an x-ray of the lumbar spine revealed interbody fusion between L1 and L2 which was suggestive of an old injury, and in June 2005 opined that "[i]t appears that this patient has a service- connected injury ever since 1944" after noting the Veteran's report of continued back pain since service discharge, the August 2009 VA examiner found that he could not state that the Veteran's reported in-service injury caused his current low back disorder without resort to speculation and ultimately opined that the Veteran's current low back disorder was most likely due to age, post-service injuries, and post-service occupations. Initially, the Board finds that the reports from A. Manguoglu and F. Smith noting that the Veteran had injured his back in service are not competent medical evidence because they are merely reciting the Veteran's reported history. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (holding that a bare transcription of a lay history is not transformed into "competent medical evidence" merely because the transcriber happens to be a medical professional). Further, although Dr. Baig reported in January 2005 that an x-ray of the lumbar spine was suggestive of an old injury, the Board cannot conclude that x-ray evidence suggestive of an old injury necessarily reflects a service etiology for the Veteran's current low back disorder. In this regard, the Board recognizes that Dr. Baig's June 2005 opinion cannot be rejected solely because it is primarily based upon history supplied by the Veteran. See Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005). However, the objective evidence of record does not support Dr. Baig's opinion and does not corroborate the Veteran's reports of ongoing low back pain and medical treatment for his low back disorder since service discharge. Specifically, during a January 1947 VA examination, the Veteran did not indicate any problems with his lower back. He also reported that he did not undergo any medical treatment since service discharge. In addition, the record is wholly devoid of any treatment for low back pain before November 2001. While the Veteran reported ongoing treatment for his back after service discharge from doctors who are now deceased, there is no evidence to corroborate these statements. Furthermore, the earliest records documenting post-service treatment for back problems shows numerous instances in 2002 in which he complaints of back pain after recent injuries, and made no reference to any prior history of back problems since service. Thus, the Board does not find the Veteran's statements with regard to continuity of symptomatology since service to be credible. In addition, there is no indication that Dr. Baig reviewed the Veteran's medical history or the claims file prior to rendering an opinion, to include the numerous reports of post-service low back injuries, which were considered and discussed by the VA examiner. Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (holding that factors for assessing the probative value of a medical opinion include access to the claims file and the thoroughness and detail of the opinion); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (the failure of the physician to provide a basis for an opinion goes to the weight or credibility of the evidence). For these reasons, the Board finds that Dr. Baig's June 2005 opinion is of little probative value. In this case, the Board affords more weight to the opinion provided by the August 2009 VA examiner, because it was made in conjunction with consideration of the Veteran's entire claims file and an interview and examination of the Veteran, and it provided supporting rationale for its opinion. Prejean, 13 Vet. App. at 448-9; Hernandez-Toyens, 11 Vet. App. at 382. The VA examiner provided the reasons and bases for the finding that he could not state that the Veteran's low back disorder was related to his in-service injury without resort to mere speculation and his ultimate conclusion that the Veteran's current low back disorder was most likely due to post-service injuries and occupations. Moreover, the VA examiner's opinion takes into consideration the Veteran's complaints of an in-service back injury and his reports that he has continued to have low back pain since service discharge. Thus, the weight of the probative medical evidence of record does not support a nexus between the Veteran's current low back disorder and active duty service. The Board acknowledges the Veteran's statements that he had low back pain and symptomatology since service discharge; however, the more probative medical evidence indicates that the Veteran's low back disorder is related to his age, multiple documented post-service injuries, and his post- service occupations, rather than an in-service low back injury. Layno, 6 Vet. App. at 469-70. As previously noted, the August 2009 VA examiner reviewed all of the evidence of record, to include the Veteran's statements of continuity of symptomatology, and based on that review, the clinical findings of the examination, and a review of the evidence in the claims file, concluded that the Veteran's low back disorder was most likely due to post-service injuries, post- service occupations, and his age. See Barr, 21 Vet. App. at 307 (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). Moreover, as discussed above, the Board does not find the Veteran's statements regarding continuity of symptomatology for his low back disorder since service discharge to be credible. Further, although the Veteran reported that he had medical treatment for a low back disorder since service discharge, the first medical evidence of record reflecting complaints of and treatment for low back pain was in November 2001, over 54 years after service discharge. Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the Veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of disorder). Accordingly, as there is no probative medical evidence that the Veteran's low back disorder is related to service, service connection is not warranted. As there is no probative medical evidence of a nexus between the Veteran's current low back disorder and his active duty service, the preponderance of the evidence is against his claim. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a low back disorder is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs