Citation Nr: 1005072 Decision Date: 02/03/10 Archive Date: 02/18/10 DOCKET NO. 95-21 565 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been submitted to reopen a service connection claim for a lumbar spine disability 2. Entitlement to service connection for a lumbar spine disability (back disability). 3. Entitlement to service connection for a cervical spine disability (neck disability), to include arthritis and shoulder problems. 4. Entitlement to service connection for a right hand disability, to include arthritis. 5. Entitlement to service connection for a left hand disability, to include arthritis. 6. Entitlement to service connection for hypertension. 7. Entitlement to service connection for right ear hearing loss. 8. Entitlement to an increased (compensable) rating for hemorrhoids. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A.G. Alderman, Associate Counsel INTRODUCTION The Veteran had active service from October 1973 to September 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 1992, February 1996, January 2001, and April 2001 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. The case returns to the Board following remands to the RO in June 1998, May 1999, September 2001, and January 2006. Review of the record shows that the Veteran's August 2002 substantive appeal included a request for a Travel Board hearing. However, correspondence received in October 2003 indicated that he desired a hearing at the RO in lieu of a Board hearing. The RO hearing was held in December 2003. The Veteran's Travel Board hearing request is considered withdrawn. The Board notes that during the December 2003 personal hearing at the RO, the Veteran indicated that he was not seeking separate service connection for a shoulder disorder. He explained that his shoulder problems were related to his cervical spine disorder. In the subsequent March 2004 supplemental statement of the case, the RO removed the claim for service connection for a shoulder disorder as a separate issue and incorporated the shoulder complaints in the claim for service connection for a cervical spine disorder. The issue as set forth above continues to characterize the claim for a cervical spine disorder in this manner. The issue of service connection for right ear hearing loss is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Board refused to reopen the Veteran's claim for entitlement to service connection for a lumbar spine disability in April 1982. Board decisions are final. 2. The Veteran submitted evidence not previously submitted to agency decision makers which bears directly and substantially upon his claim for service connection for a lumbar spine disability; which is neither cumulative nor redundant; and which, by itself or in connection with evidence previously assembled, is so significant that it must be considered in order to fairly decide the merits of the claim. 2. The Veteran's lumbar and cervical spine disability, to include arthritis and shoulder problems, were not incurred during or as a result of active service. 3. The Veteran's bilateral hand disability is related to his in-service injury. 4. The Veteran's hypertension did not have onset during active service, did not have onset within one year of separation from active service, and is not otherwise related to active service. 5. The Veteran's hemorrhoids are not large or thrombotic, or irreducible with excessive redundant tissue evidencing frequent recurrences. CONCLUSIONS OF LAW 1. The Board decision of April 1982 that denied reopening the claim of entitlement to service connection for a lumbar spine disability is final. 38 U.S.C.A. §§ 7104, 7105(c) (West 2002); 38 C.F.R. §§ 20.1100, 20.1103 (2009). 2. New and material evidence has been submitted to reopen the previously denied claim for service connection for a lumbar spine disability. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. 3. The criteria for service connection for a lumbar and cervical spine disability, to include shoulder problems and arthritis, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303 (2009). 4. The criteria for service connection for a bilateral hand disability have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303 (2009). 5. The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2009). 6. The criteria for an initial compensable evaluation for service-connected hemorrhoids have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.114, DC 7336 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. New and Material Governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing and, after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. Rating actions from which an appeal is not timely perfected become final. 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. In general, Board decisions are final. 38 U.S.C.A. § 7104; 38 C.F.R. § 20.1100. A final decision cannot be reopened unless new and material evidence is presented. 38 U.S.C.A. § 5108. The Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with respect to that claim. Knightly v. Brown, 6 Vet. App. 200 (1994). For claims filed prior to August 29, 2001, new and material evidence is defined as evidence not previously submitted to agency decisionmakers which bears directly and substantially upon the specific matter under consideration; which is neither cumulative nor redundant; and which, by itself or in connection with evidence previously assembled, is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (2001). Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the United States Court of Appeals for the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). In this case the Veteran seeks to reopen a claim for service connection for a lumbar spine disability. The RO initially denied service connection for a spine disability in December 1977, a decision that was upheld by the Board in January 1979, because the evidence failed to show a chronic spine disorder. The Veteran filed a new claim for service connection for a spine disorder in January 1980. The RO denied the claim in February 1980 and the Board upheld the decision in April 1982 as the Veteran failed to submit new and material evidence to reopen his claims. The Board decision of April 1982 is final. The basis for the Veteran's initial denial of service connection for the lumbar spine disability was lack of a diagnosed disability. Since the April 1982 decision, the Veteran has submitted medical evidence showing a diagnosed disability and letters from private medical providers linking the lumbar spine disability to his active service. Therefore, the Board finds that new and material evidence has been submitted to reopen the previously denied claim. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. II. Service Connection Service connection may 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 line of duty, in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2009). Service connection may be demonstrated either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection for organic diseases of the nervous system, such as hearing loss, and for certain chronic diseases, including hypertension, may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one (1) year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2009). Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993). See also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Simply put, to establish service connection, there must be: (1) A medical diagnosis of a current disability; (2) medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd 78 F.3d 604 (Fed. Cir. 1996). Additionally, service connection may be granted, on a secondary basis, for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310 (2009). The Veteran seeks service connection for hypertension, a bilateral hand disability, lumbar spine arthritis, and cervical spine arthritis with residual shoulder impairment as a result of an accident in service during which a hatch of a truck was dropped on the Veteran's forearms, breaking both forearms. A. Lumbar and Cervical Spine The Veteran's service treatment records (STRs) show that the Veteran complained of back pain in April 1974. The record states that the Veteran had been seen for back pain before. In January 1975, the Veteran complained of back pain lasting several days as a result of playing basketball and heavy lifting. He was diagnosed with lumbar strain. In January 1976, the Veteran complained of muscle spasm and pain of his right middle back. The diagnosis was muscle spasm secondary to possible lifting. A July 1976 record indicates that the Veteran was treated for broken forearms as a result of the Veteran's forearms getting caught over a tailgate of a truck while it was backing up. In August 1976, a record shows that the Veteran was treated for his broken forearms resulting from a hatch of a truck dropping on him. His treatment records from the accident do not indicate that the Veteran injured his lumbar or cervical spine, shoulders or hands during this incident. The separation examination, dated September 1976, does not indicate abnormalities of the spine. Over the years, the Veteran has been treated for his hands, shoulder pain, and arthritis of the lumbar and cervical spine. A June 1977 VA outpatient treatment record shows that the Veteran reported that a truck pinned him against a loading dock in July 1976. He said that the truck pressed against his chest. The treatment record stated that the Veteran's spine was within normal limits. It is noted that the STRs fail to indicate that a truck pinned the Veteran and fail to indicate injury to the Veteran's chest or spine as a result of the 1976 accident. In October 1977, the Veteran was afforded a VA examination. The Veteran had 95 percent of normal range of motion of the lumbar spine, with range of motion bending to the right being a little easier than bending to the left. Also noted was tenderness at the lumbosacral junction with radiation and pressure. The diagnosis was low back strain by history. A record dated April 1986 from Dr. C.O.S., MD states that the Veteran complained of neck pain. The Veteran reported that his left shoulder and upper arm were crushed between two heavy structures and that he sustained broken forearms. The STRs fail to show that the in-service injury involved the shoulders or upper arms. The diagnosis was weakness and pain that might be due to cervical disc disease. Multiple VA outpatient treatment records address the Veteran's lumbar and cervical spine disabilities. Most of the records show that the Veteran said his spine disabilities are the result of an in-service injury that crushed his chest based on the history as provided by the Veteran; however, as noted, the Veteran's STRs fail to support the Veteran's reported history regarding the etiology of his spine disorder. A radiologic report from April 1994 indicates that the cervical spine had degenerative changes; however, there was no evidence of recent or old trauma. The Veteran had a VA examination in September 1995. The examiner did not indicate review of the claims file and it appears that the Veteran again reported that his chest was crushed during the in-service injury, causing rib fractures, deflated lungs, and fractures of the forearms. As noted, the STRs only indicate that the Veteran fractured his forearms. There is no evidence in the STRs to support the Veteran's allegations of impact on the chest, rib fractures, or lung injuries. The examiner was unable to determine the etiology of the Veteran's neck pain. No other opinions were provided. A VA examination, dated February 1996 addresses the lumbar and cervical spine pain but the examiner did not provide an opinion regarding the etiology of the disabilities. A letter from a private radiologist, Dr. K.B.A., MD, dated January 1997, indicates that the Veteran has degenerative changes of the cervical and lumbar spines. He stated that considering the Veteran's age and his history of severe trauma sustained in military service, one should consider the possibility of accelerated degenerative change of the cervical, thoracic, and lumbar spines. However, the Board notes that Dr. K.B.A. did not indicate review of the Veteran's STRs and that at best, his opinion is speculative. Also submitted on the Veteran's behalf are letters from Dr. P.E.V., D.C., dated August 1998 and December 1999. In these letters, Dr. P.E.V. states that the Veteran told him he was pinned by a large military truck against a loading dock and that he sustained forearm fractures and spinal injuries. Again, it is noted that there are no spinal injuries indicated in the STRs in relation to the 1976 in-service injury. Dr. P.E.V. noted that the Veteran has degenerative changes of the spine and that considering his age and the uniqueness of the trauma, that the Veteran's symptoms will be recurrent. Unfortunately it does not appear that Dr. P.E.V.'s opinion was based upon a review of the STRs and is based upon what appears to be inaccurate history provided by the Veteran. Therefore, any opinion expressing a link between the spine disabilities and the in-service accident has little probative weight. In a July 1998 letter from the Veteran's private physician, Dr. M.A.F., MD, he states that the Veteran told him he was pinned by a military truck in service, causing injury to his spine. Dr. M.A.F. did not indicate review of the STRs and said that based upon the history provided by the Veteran, that the Veteran's spinal changes are premature and have been accelerated by the trauma incurred in 1976. Since Dr. M.A.F.'s opinion is not based upon a review of the STRs and appears to be based upon inaccurate history provided by the Veteran, his opinion expressing a link between the Veteran's spine disabilities and the in-service accident is found to have little probative weight. The Veteran had a VA examination in December 1999. The examiner reviewed the claims file in conjunction with the examination. The examiner stated that upon review of the Veteran's claims file, including STRs, there was no mention of injury to the Veteran's chest, neck, back, or shoulder in the STRs. After a physical examination, the examiner diagnosed the Veteran with degenerative disc disease of the cervical spine. He further stated that there is no objective evidence of organic pathology of the left shoulder or lumbar spine. He said that the tiny osteophytes noted on the x-rays are seen in many people of the Veteran's age and are changes secondary to aging. In the opinion, the examiner stated that the Veteran's current cervical spine, left shoulder, and lumbar spine disabilities are not related to his forearm fractures which he sustained in 1976. He stated that the disabilities are more likely than not unrelated to the in-service injuries. In an addendum, dated March 2000, the examiner further stated that the only abnormality present in the lumbar spine are the small osteophytes. He said that there was no narrowing of the disc or subchondral sclerosis and that osteophytes, such as the Veteran's, are seen in 40 percent of the people over the age of 35. He stated that one could conclude that the osteophytes are the first evidence of degenerative disc disease and that the 40 percent of the people over the age of 35, including the Veteran, all have early degenerative disc disease. He concluded that it is more likely than not that the Veteran's changes are unrelated to his in-service injury, providing what the Board finds to be highly probative evidence against this claim, providing a detailed basis for the opinion. The Veteran had another VA spine examination in June 2003. The examiner reviewed the claims file. The examiner provided a history given by the Veteran. After a physical examination, the diagnosis was chronic low back pain due to mild osteoarthritis, pain in the neck due to degenerative joint disease changes, and left shoulder pain with no cause found and normal x-rays. The opinion was low back pain, chronic neck pain and shoulder pain not at least as likely as not related to military service or any incident within service. The opinion was based upon a review of the claims file and history as well as the physical examination. In August 2004 and April 2005, the Board requested expert medical opinions to determine the etiology of the Veteran's disabilities. Specifically, VA asked experts to indicate whether the trauma reported during the Veteran's service resulted in accelerated or aggravated disabilities, including but not limited to the spine and shoulder disabilities. The examiner was also asked to indicate whether the Veteran's spine and shoulder disabilities are related to active service or whether they had onset during service. In July 2005, the VA neurologist indicated that after a review of the claims file, it is less likely than not that the trauma reported by the Veteran and documented in the medical record resulted in the accelerated or aggravated disabilities of the cervical spine, shoulder, lower back, and hands. The examiner stated that the accounts of the original injury suggest that the main injury occurred in the forearm and wrist regions and that no other injuries of substance were reported or cared for at the time of the initial event in 1976. The examiner stated that prior to the injury, the Veteran reported back pain in relationship with his tasks and activities of a physical nature, which resulted in ongoing back pain for which he did not seek medical attention at sick bay. The Veteran was evaluated in service and subsequent to service with neurologic, orthopedic, radiological, as well as medical personnel; however, the testing did not corroborate the Veteran's complaints. The examiner stated that the cervical and lumbosacral spinal degenerative disease is ubiquitous and radiological evidence for this can be present in individuals in their early to mid 20s and that the changes are more common as individuals age. He stated that by age 50, these changes can be seen in upwards of 70% of the population. Further, the type of injury described and recorded in the Veteran's service treatment records (STRs) was mainly confined to the forearm. The neurologist stated that it is unlikely that the trauma to the forearm could result in accelerated or aggravated disability in the spinal column. The examiner further stated that the Veteran has a degenerative arthritic condition but that it would be difficult to pinpoint when the condition began. The examiner stated that complaints commensurate with degenerative joint disease, which can be attributed to a lumbar sprain or strain, were recorded while the Veteran was on active duty. He stated that the complaints preceded the 1976 injury to the forearms and that there are several visits to the sick bay where the Veteran complained of low back pain and was diagnosed with lumbar sprain/strain. However, the examiner opined that the generalized degenerative conditions involving the lumbar and cervical spine and hands are mainly degenerative in nature and most likely secondary to normal and expected effects of aging. In May 2005, a VA expert in orthopedics reviewed the Veteran's claims file and stated that it is not as likely as not that the trauma reported by the Veteran in service resulted in or accelerated or aggravated disabilities of the cervical spine, shoulder, low back, and hands. He further stated that the Veteran does have generalized arthritic or degenerative conditions which are not a result of and did not have onset during active military service. The examiner stated that there is no documented evidence of injury to the cervical or lumbar spine, shoulders, or hands as a result of the 1976 injury to the forearms. He stated that the 1976 injury was not such that it would be expected to lead to subsequent disability in remote areas such as the neck or back not involved in the initial injury. The examiner stated that while the cervical and lumbosacral spine derangements subsequently diagnosed are degenerative in nature, on occasion, they may be precipitated by derangements in other areas which alter the structural load in the spinal column. He stated that this is not the case in the Veteran's injuries, therefore it is not likely that the trauma of the injury to the forearms resulted in accelerated or aggravated disabilities in the cervical or lumbar spine, shoulder, and hands. He further stated that the generalized arthritic condition involving the cervical spine, lumbosacral spine, shoulder and hands is of a degenerative nature and is the result of the normal and expected effects of the aging process and not the result of injury or activity during the Veteran's active service. The Board has thoroughly reviewed all of the evidence and notes that the few medical opinions supporting a nexus between service and the Veteran's lumbar and cervical spine disabilities, with shoulder residual, are based upon a seemingly inaccurate history provided by the Veteran and unsupported by the STRs. The Veteran repeatedly reported that he injured his chest and spine during the accident in 1976; however, medical records fail to indicate that the Veteran hurt his chest or spine during this incident. Medical records only indicate injuries to the forearms. The report in service appears very complete, providing evidence against this claim. Post-injury service treatment records only support the denial of the Veteran's central contention. The Board finds that the May and July 2005 VA expert opinions as well as the VA examinations of June 2003 and December 1999, with March 2000 addendum, are more probative of the issue of service connection for the lumbar disability and cervical spine with shoulder disability as each examiner had the benefit of reviewing the entire claims file and the STRs and, as whole, provide better explanations for their opinions. While a review of STRs is not required, in this case it is critical in the understanding of what the Veteran did (or did not) injure during his military service. These examiner stated that the Veteran's claimed disabilities are more likely than not related to aging and not to the 1976 in-service trauma to the forearms or to the lumbar strain suffered prior to the 1976 accident. The examiners supported their opinions with rationale, as discussed above, that the Board find convincing. The Board has considered the Veteran's statements regarding the etiology of his disabilities, including his testimony before the RO and DRO, but finds that the medical evidence is more probative as the STRs and other medical records fail to support the Veteran's history of events, actually providing highly probative evidence against his history of events that are found more probative than the Veteran's statements. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not applicable, and the claims must be denied. 38 U.S.C.A. § 5107(b). Service connection for a lumbar and cervical spine disability, to include arthritis and shoulder problems, is denied. B. Bilateral Hands, Arthritis The Veteran seeks service connection for a bilateral hand disability, to include arthritis. As noted above, the Veteran's forearms were broken when the hatch of a truck fell on them during service. Treatment records from the accident do not indicate that the Veteran injured his hands. Subsequent to service, the Veteran was treated by VA in January 1977. The physician found that the Veteran's fractures of the forearms were healing, with no other abnormalities present. In March 1977, the Veteran could make a strong grip with both hands and showed no evidence of loss of muscle bulk or strength in the arms, forearms, and hands. The record also stated that there was no loss of sensory acuity, weighing against the Veteran's claim. However, a June 1977 record indicates that the Veteran's neurological examination was grossly within normal limits except for the weakness noted in the extremities which was probably secondary to previous trauma, weighing in favor of the Veteran's claim. In October 1977, the Veteran was afforded a VA examination. He complained of numbness of the right hand, but the examiner did not provide a diagnosis or an opinion. A private treatment record from Dr. C.O.S., MD, PA, dated August 1980, noted that the Veteran had decreased strength in his hands due to surgery, weighing in favor of the Veteran's claim. VA outpatient treatment records dated September 1980 show that the Veteran complained of his hands. Dr. C.O.S.'s records show that the Veteran again complained about weakness of his hands in April 1986. An EMG conducted in July 1987 failed to show any abnormalities in the left or right upper limbs. VA outpatient treatment records dated February 1987 show that the Veteran complained about not being able to work due to his hands. VA outpatient treatment records dated March 1991 indicate that the Veteran had arthritis of the left hand due to surgery, weighing in favor of the Veteran's claim. An August 1995 treatment record diagnoses the Veteran with arthritis of the hands. An x-ray report dated January 1996 from Baptist Memorial shows that the Veteran had early osteoarthritic changes at the first carpal metacarpal joint of the left hand. The Veteran was afforded another VA examination in February 1996. The examiner did not review the claims file. The Veteran complained of popping around in his right hand on opening and closing the hand. He also complained of decreased sensory perception to pinprick over the entire left had as compared with the right. He stated that the numbness in the left hand had been present for only a few months. The examiner stated that he does not know why the Veteran has loss of sensory perception in his entire left hand. No further opinions or comments were provided regarding the Veteran's claimed bilateral hand disability. A VA outpatient treatment record dated April 1996 shows that the Veteran was diagnosed with carpal tunnel syndrome (CTS). In September 1996, the Veteran had another VA examination. The examiner did not review the claims file in conjunction with the examination. The examiner found no evidence of arthritis of the metacarpophalangeal joints but indicated that the symptoms are suggestive of episodic CTS. The x-rays showed that the Veteran's hands were normal. An opinion regarding the etiology of the Veteran's bilateral hand disability was not provided. A letter from a civilian radiologist, Dr. K.B.A., MD, dated January 1997, states that considering the Veteran's history of severe trauma sustained during military service, the possibility of accelerated degenerative change of the wrists should be considered. The Veteran had another VA examination in December 1999. The examiner reviewed the claims file. In the diagnosis, the examiner stated that on physical and x-ray examination, he could find no objective evidence of organic pathology in either hand. After reviewing the Veteran's STRs and claims file, and after performing a physical and x-ray examination, the examiner stated that he does not believe that the Veteran's current bilateral hand conditions are related to his injury in service. He stated that the hand conditions are more likely than not unrelated to his in-service injuries. No rationale for the opinion was provided. The Veteran had a VA joints and neurological examination in June 2003. The general examiner reviewed the claims file. On examination, the examiner found that the Veteran had good range of motion and good grip with both hands. The x-rays of both hands were normal. A diagnosis of the hands was not provided nor was an opinion regarding the etiology of any hand symptomatology. The neurological examination showed mild hypoesthesia in the little fingers and ring fingers. An opinion regarding the etiology of the hand abnormalities was not provided. The Board also reviewed the VHA expert neurologic and orthopaedic opinions obtained in May and July 2005, as discussed above. Both examiners indicated that the condition of the hands is of a degenerative nature and is the result of the normal and expected effects of the aging process and not the result of injury or activity during the Veteran's active service. The opinions were based upon a review of the claims file and each examiner stated that there is no documented evidence of injury to the hands as a result of the 1976 injury to the forearms, thus weighing against the Veteran's claim. The Board has considered all evidence in the claims file, including the Veteran's statements. The evidence includes medical opinions that favor as well as medical opinions that oppose a finding that the bilateral hand condition is related to service. Opinions finding no relation to service, in general, are either unsupported by rationale, based upon the STRs' failure to specifically indicate an injury to the hands during service, or were made without the benefit of reviewing the entire claims file. The negative opinions do not address whether the bilateral hand disability is, or could be, secondary to the forearm fractures incurred during service. Due to the direct proximity of the hands to the forearms, and because during his follow-up treatment medical records show some numbness of the hands related to the forearm surgeries, the Board believes that the Veteran's in-service forearm fractures could have impacted the Veteran's hands. This theory is supported by the June 1977 medical record which states that the Veteran had weakness in the extremities that is probably secondary to previous trauma (a highly probative piece of medical evidence). August 1980 and March 1991 medical records note that the Veteran had decreased strength in his hands due to surgery. Other medical records support the Veteran's position that his bilateral hand condition is related to his forearm fracture in service. In sum, the Board finds that the evidence is at least in relative equipoise; therefore, the benefit of the doubt should be given to the Veteran. Accordingly, the Veteran's claim for service connection for a bilateral hand disability is granted. The nature and extent of the bilateral hand disability related to service is not before the Board at this time. C. Hypertension The Veteran seeks service connection for hypertension. The entrance examination, dated September 1973, shows that the Veteran's blood pressure was 124/74. His separation examination showed a blood pressure reading of 110/80. The STRs do not show that the Veteran was treated for hypertension during service or that he had elevated blood pressure readings or symptoms of hypertension during his period of active service. Subsequent to service, the medical records fail to show that the Veteran was diagnosed with hypertension within one year of separation from service. A record dated November 1985 indicates that the Veteran's blood pressure reading was 140/102; however a diagnosis of hypertension was not indicated. The first evidence of hypertension is in a VA outpatient treatment record dated April 1996. The record shows that the Veteran's blood pressure was 136/94. Records dated July and October 1997 diagnose the Veteran with hypertension. A note from the Veteran's VA physician, K.C., dated November 2000, indicates that she has treated the Veteran for six years for hypertension. A letter from the Veteran's private physician, Dr. J.E.S., MD, dated July 2001, indicates that the Veteran has a history of hypertension which is fairly well controlled. Neither writing indicated the etiology of the Veteran's hypertension. Finally, a VA outpatient treatment record, dated May 2005, indicates that the Veteran reported a history of hypertension while in the military. The medical provider did not indicate the etiology of the Veteran's hypertension. The Veteran has stated that his hypertension is the result of or had onset during active service. Because he has not demonstrated that he has the medical expertise of other than a layperson, his opinion as to complex medical matters are not competent evidence. See Routen v. Brown, 10 Vet. App. 183, 186 (1997). See also Bostain v. West, 11 Vet. App. 124, 127 (1998) citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992) (a layperson without the appropriate medical training and expertise is not competent to provide a probative opinion on a medical matter, to include a diagnosis of a specific disability and a determination of the origins of a specific disorder). This is not to say that a layperson may never provide competent evidence as to what may, at first inspection, appear to be a medical question. When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Additionally, lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In Jandreau, the Federal Circuit indicated that the type of evidence that a layperson is competent to provide depends on the complexity of the issue involved. Id. (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex questions, such as a type of cancer). Consequently, though the Veteran has stated his belief that his hypertension is the result of his service, the Board finds that an opinion as to the etiology of his hypertension is beyond the competency of a layperson. Further, elevated blood pressure appears to have been first noted in 1985, with the first diagnosis of hypertension appearing in 1996, almost 20 years after separation from service. The United States Court of Appeals for the Federal Circuit has determined that a substantial a lapse of time between separation from service and post-service treatment for the claimed disorder is a factor for consideration in deciding a service connection claim. Maxson v. Gober, 230 F.3rd 1330, 1333 (Fed. Cir. 2000). Based upon a review of the evidence, the Board finds that the preponderance of the evidence is against a finding of service connection as the evidence fails to show that the Veteran's hypertension is in any way related to his active service. The Board further finds that there is no competent evidence to show that the Veteran had hypertension that was manifest to a compensable degree within one year of separation from active service and that the post-service treatment records, as a whole, provide evidence against such a finding. Accordingly, the Board finds that the preponderance of the evidence is against the claim and that the claim must be denied. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2009). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding the Veteran's increased evaluation claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the U.S. Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period (as in this case). Id. at 126. Hart appears to extend Fenderson to all increased evaluation claims. The Veteran seeks a compensable rating for his hemorrhoids. The RO rated the Veteran under 38 C.F.R. § 4.114, Diagnostic Code (DC) 7336 (2009). External or internal hemorrhoids are rated pursuant to 38 C.F.R. § 4.114, DC 7336. A noncompensable evaluation is assigned for milder or moderate hemorrhoids; a 10 percent rating is assigned for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue evidencing frequent recurrences; and a 20 percent evaluation is assigned for hemorrhoids with persistent bleeding and with secondary anemia or with fissures. The evidence shows that the Veteran was treated for his hemorrhoids on several occasions since the commencement of his claims. In May 2006 he had a colonoscopy and was found to have wide mouth right sided diverticula and external hemorrhoids. In August 2005, the Veteran reported rectal bleeding. In August 2003, the Veteran was treated by Dr. A.T.W. (Williams) (Dr. A.W.), for rectal bleeding. The rectal tone was normal. Another record from Dr. A.W., dated August 2001 indicates that the Veteran had a colonoscopy, which found internal hemorrhoids. No masses or polyps were seen. Dr. A.W. stated that the Veteran's rectal bleeding is likely secondary to hemorrhoids as no other significant pathology was found. VA outpatient treatment records dated August 2001 showed an assessment of hemorrhoid discomfort. A VA examination, dated December 2000, found non-inflamed hemorrhoidal tags externally. Internally the examiner found tender varicosities without evidence of bleeding. The Board has reviewed all evidence in the claims file, including the Veteran's statements and testimony, as well as VA and private treatment records and buddy statements. Based upon the evidence in the claims file, the Board cannot find that the Veteran's hemorrhoids warrant a compensable rating at this time. The evidence does not show large or thrombotic, irreducible hemorrhoids with excessive redundant tissue evidencing frequent recurrences or hemorrhoids with persistent bleeding and with secondary anemia or with fissures. Accordingly, the Board finds that the Veteran's disability picture more closely resembles the criteria for a noncompensable rating as his occasional flare-ups are at most, moderate in degree. The Board finds that the post- service treatment records provide evidence against this claim, outweighing the Veteran's statements. The potential application of various provisions of Title 38 of the Code of Federal Regulations has also been considered but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1). In this regard, the Board finds that there has been no showing by the Veteran that the service- connected disorder has resulted in marked interference with employment or that it has necessitated frequent periods of hospitalization. In the absence of such factors, the Board finds that criteria for submissions for assignment of the extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Finally, in making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. The Veteran may always advance a new claim for an increased rating should his hemorrhoids increase in severity in the future; however, based on the evidence currently of record, an increased rating is not warranted. III. The Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), which was enacted on November 9, 2000, eliminated the concept of a well-grounded claim, redefined the obligations of VA with respect to the duty to assist, and imposed on VA certain notification requirements. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, & 5126; 38 C.F.R. § 3.159 (2009). Under the 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. 2009); 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 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 in accordance with 38 C.F.R. § 3.159(b)(1). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that VA must also notify the claimant that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. For an increased-compensation claim, section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) rev'd in part by Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. Sept. 4, 2009). Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Id. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the U.S. Court of Appeals for Veterans Claims (Court) held, in part, that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction or regional office (RO) decision on a claim for VA benefits. In the present case, the unfavorable RO decisions that are the basis of this appeal were already decided and appealed prior to the enactment of the current section 5103(a) requirements in 2000. The Court acknowledged in Pelegrini that where, as here, the § 5103(a) notice was not mandated at the time of the initial RO decision, the RO did not err in not providing such notice. Rather, the Veteran has the right to a content complying notice and proper subsequent VA process. Pelegrini, 18 Vet. App. at 120. Briefly, the Board notes that since the Veteran's claim for service connection for a lumbar spine disability has been reopened, any deficiency in notice under the VCAA, Kent v. Nicholson, 20 Vet. App. 1 (2006), or otherwise, is not prejudicial to the Veteran and will not be further discussed. With regard to the service connection and increased rating claims, in July 2001 the RO sent VCAA notice for the service connection claim for hypertension and notified the Veteran of the evidence necessary to substantiate the claim; the evidence that VA will seek to provide; and of the evidence he is expected to provide. The RO also notified the Veteran that to substantiate a claim for an increased rating, he must provide evidence showing that the service connected disability had worsened. In March 2002, the RO sent VCAA notice for the service connection claims for a bilateral hand disability, lumbar spine disability, and cervical spine disability with associated shoulder issues. The letter informed the Veteran of the evidence necessary to substantiate the claims; the evidence that VA will seek to provide; and of the evidence he is expected to provide. In April 2006, the Appeals Management Center (AMC) sent the Veteran notice of (1) how to substantiate all of his service connection claims; (2) the evidence that VA will seek to provide; and (3) the evidence he is expected to provide. The notice also included basic increased rating criteria (i.e. worsening of the disability) and notice of how disability ratings and effective dates are assigned. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). A separate letter addressing the Dingess criteria was sent to the Veteran in March 2006. It is noted that Veteran was not specifically provided Vazquez-Flores notice for his increased rating claim; however, the Board notes that the July 2001 and April 2006 VCAA letters notified the Veteran that he must provide evidence showing that his disability worsened. The April 2006 VCAA letter and March 2006 Dingess letter informed the Veteran of the different types of evidence that that he could provide to support his claim and that he could submit evidence showing an increase in severity of the disability and the effect that worsening has on his employment. The March 2006 Dingess letter also informed the Veteran that should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment. Finally, in a statement from the Veteran's personal representative, dated May 2004, the representative quoted the relevant diagnostic code and criteria for rating hemorrhoids, thus indicating that the Veteran was aware of the criteria necessary for an increased rating. Several supplemental statements of the case were issued on the claims, with a final supplemental statement of the case being issued in June 2009, readjudicating all claims on appeal. Thus, based on the foregoing, the Board finds that the Veteran has been provided with adequate VCAA notice and finds that he has not been prejudiced because he has been provided ample opportunity respond to the notice letters and because VA issued the June 2009 supplemental statement of the case readjudicating the Veteran's claims. Therefore, the Board finds that the criteria under Pelegrini, 18 Vet. App. at 120, has been satisfied. Further, the Board must note that this case has been going on for many years and that there is every reason to believe that the Veteran understands what evidence he must submit. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran was provided a VA examination for all of his claimed disabilities except hypertension. The Board finds that a VA examination was not warranted for the service connection claim for hypertension as the evidence failed to show hypertension or elevated blood pressure during service. The evidence failed to show elevated blood pressure until November 1985, over 9 years after separation from service. The first indication of hypertension is dated April 1996. More importantly, none of the medical evidence relates the Veteran's hypertension to his period of active service. The Veteran has stated his belief that his hypertension is the result of service; however, as noted above, the Veteran does not have the expertise to render an opinion about hypertension as it is not unique and readily identifiable, the presence of the disorder is a determination "medical in nature" and it is not capable of lay observation. Therefore, without evidence indicating that hypertension may be related to service, a VA examination is not warranted. The Board finds that all necessary development has been accomplished; therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained or been provided with STRs, VA outpatient treatment records, private treatment records, buddy statements, and statements from the Veteran. The Veteran was provided an opportunity to set forth his contentions during hearings before the RO in February 1994 and DRO in December 2003. The Veteran has been afforded multiple VA medical examinations for each disability, with the exception of hypertension, as discussed above. VHA expert opinions regarding the Veteran's disabilities have also been obtained. Accordingly, the Board finds that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Further development of these claims would serve no constructive purpose. Extensive development of this case has been undertaken over many years and further efforts that would delay the adjudication of a case are clearly not warranted ORDER New and material evidence has been received since the April 1982 Board decision; therefore the claim for service connection for a lumbar spine disability is reopened. Service connection for a lumbar and cervical spine disability, to include arthritis and shoulder problems, is denied. Service connection for a bilateral hand disability is granted. Service connection for hypertension is denied. Entitlement to a compensable rating for hemorrhoids is denied. REMAND The Board notes that the Veteran's right ear hearing loss claim was denied by the RO in October 1992. The Veteran filed a notice of disagreement in September 1993 and was issued a statement of the case in October 1993. In October 1993, the Veteran filed his substantive appeal, VA Form 9, and had a hearing before the RO in February 1994. Subsequent to the hearing, a supplemental statement of the case was issued in February 1994. The claim was never forwarded to the Board for adjudication. In June 2000, the Veteran filed another claim for his right ear hearing loss. Despite the claim remaining on appeal, along with multiple other issues awaiting Board review, the RO treated the claim as a new and material evidence claim. The Board finds that the current appeal stems from the original claim as all proper procedures were followed. Regarding this claim, the Board notes that the RO granted the Veteran a VA examination in October 1992 and February 2001. Neither VA examiner reviewed the claims file in conjunction with the examinations or provided an opinion regarding the etiology of the right ear hearing loss and its relation to service, if any. The Court has held that medical examinations must be thorough and take into account the records of prior examinations and treatment. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Where existing examinations are inadequate for rating purposes, a VA examination will be authorized. 38 C.F.R. § 3.326. Therefore, since the October 1992 and February 2001examiners failed to review the claims file and failed to provide an opinion regarding the disability and its relation to service, if any, a new VA examination is warranted. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA audiological examination. The claims folder must be sent to the examiner for review, and the examiner must state in the evaluation report that he/she has reviewed the claims files. The examination should include all indicated audiometric studies. The examiner is asked to review the record and indicate if it is at least as likely as not (i.e., a likelihood of 50 percent or greater) that the Veteran's right ear hearing loss (if any) is the result of his service. All opinions must be supported by rationale. 2. The RO should then readjudicate the issue on appeal. If the determination remains unfavorable to the Veteran, he should be provided with a supplemental statement of the case (SSOC) that addresses all relevant actions taken on the claim for benefits, to include a summary of the evidence and applicable law and regulations considered. The Veteran should be given an opportunity to respond to the SSOC. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs