Citation Nr: 1100537 Decision Date: 01/05/11 Archive Date: 01/14/11 DOCKET NO. 03-15 795 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for a chronic right wrist disorder to include arthritis. 2. Entitlement to service connection for a chronic left wrist disorder to include arthritis. 3. Entitlement to service connection for a chronic left shoulder disorder to include arthritis. 4. Entitlement to an initial evaluation in excess of 30 percent prior to January 4, 2010 and entitlement to an evaluation in excess of 50 percent since January 4, 2010 for posttraumatic stress disorder (PTSD). 5. Entitlement to an effective date earlier than April 24, 2007, for the award of service connection for PTSD. (The issues of entitlement to an evaluation in excess of 10 percent for chronic degenerative osteoarthritis of the left knee and entitlement to an initial evaluation in excess of 10 percent for left knee anterior cruciate ligament tear are the subjects of a separate decision.) REPRESENTATION Appellant represented by: Sean A. Ravin, Attorney ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran had active military service from May 1968 to February 1970. The issues of entitlement to service connection for a chronic right wrist disorder, a chronic left wrist disorder, and a chronic left shoulder disorder came back before the Board of Veterans' Appeals (Board) on Remand from the United States Court of Appeals for Veterans Claims (Court) regarding a Board decision rendered in February 2007. In September 2008, these issues were remanded by the Board for additional development. These issues were originally on appeal from a September 2002 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Detroit, Michigan. The issues of entitlement to an increased rating for PTSD and entitlement to an earlier effective date for the award of service connection for PTSD come before the Board of Veterans' Appeals (Board or BVA) on appeal from rating decisions dated in March 2009 and February 2010 of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The Board notes that the issue of entitlement to an increased evaluation for PTSD is currently on appeal. Specifically, the Veteran seeks an evaluation in excess of 30 percent prior to January 4, 2010 and an evaluation in excess of 50 percent since January 4, 2010. The Board notes that in March 2010, the RO received the Veteran's Notice of Disagreement (NOD) with the effective date (January 4, 2010) of the grant of the 50 percent disability rating. Generally, after an NOD is received, the RO must issue a Statement of the Case (SOC), and the Veteran provided an opportunity to perfect his appeal as to the issue. In this case, however, the issue of entitlement to an effective date earlier than January 4, 2010 is already included in the increased rating issue and has not been characterized as a separate issue. The issue of entitlement to an increased rating for PTSD is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. The issue of entitlement to a total disability evaluation based on individual unemployability due to service- connected disabilities (TDIU) has been raised by the Veteran and is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. A chronic right wrist disorder, to include arthritis, is not related to the Veteran's active service. 2. A chronic left wrist disorder, to include arthritis, is not related to the Veteran's active service. 3. A chronic left shoulder disorder, to include arthritis, is not related to the Veteran's active service. 4. On April 24, 2007, the RO received the Veteran's original claim for service connection for PTSD. CONCLUSIONS OF LAW 1. A chronic right wrist disability was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1154(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2010). 2. A chronic left wrist disability was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1154(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2010). 3. A chronic left shoulder disability was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1154(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2010). 4. The criteria for an effective date prior to April 24, 2007, for the grant of service connection for PTSD have not been met. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.400 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters The Board has thoroughly reviewed all the evidence in the Veteran's claims folders. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). In a February 2007 decision, the Board denied, inter alia, the Veteran's claim for service connection for a chronic left shoulder disorder, to include arthritis. The Veteran appealed the February 2007 Board decision to the Court. In May 2008, VA's Office of General Counsel and Veteran's attorney filed a Joint Motion for Remand (JMR) requesting that the Court vacate and remand the Board's February 2007 decision. In May 2008, the Court issued an Order remanding the matter. In the JMR, the parties agreed, that a remand was required as the VA examination conducted in April 2004 was inadequate because the VA examiner's opinions were not supported by a complete rationale. In September 2008, the Board remanded the case for compliance with the JMR. Pursuant to the Board's February 2007 Remand, the RO scheduled the Veteran for a VA examination to determine the etiology of any current left shoulder disability, readjudicated the Veteran's claim under provision of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) as discussed in more detail below, and issued a supplemental statement of the case. Based on the foregoing actions, the Board finds that there has been compliance with the Board's September 2008 Remand. Stegall v. West, 11 Vet. App. 268 (1998). Veterans Claims Assistance Act of 2000 As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. With respect to service connection claims, the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA has met all statutory and regulatory notice and duty to assist provisions. Letters dated in August 2003, February 2006, and March 2006 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 6 Vet. App. at 183, Dingess, 19 Vet. App. at 473. Together, the letters informed the appellant of what evidence was required to substantiate the claim and of the appellant's and VA's respective duties for obtaining evidence, as well as how VA determines disability ratings and effective dates. Ideally, the notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). Although that was not done in this case, the Board finds that this error was not prejudicial to the appellant because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the appellant been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond, but the AOJ also readjudicated the case after the notice was provided. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the AOJ's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the AOJ). For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. The Veteran's service treatment records and identified VA medical treatment records have been obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board notes that the Veteran has identified no private medical records that he wished for VA to obtain on his behalf. There is no indication in the record that any additional evidence, relevant to the issues decided herein, is available and not part of the claims file. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The Veteran was accorded VA examinations in January 2009 and December 2009. 38 C.F.R. § 3.159(c)(4). Both VA examiners addressed the etiology of the Veteran's current bilateral wrists and left shoulder disorders in conjunction with a review of the claims file and physical examination of and interview with the Veteran. The 2009 VA examination reports are thorough and adequate upon which to base a decision. The Board notes that the Veteran is represented by counsel; and there has been no assertion of any failure to provide appropriate notice. With respect to the Veteran's claim of entitlement to an earlier effective date for his award of service connection for PTSD, the Board finds that all necessary development has been accomplished; and, therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In this case, no additional assistance could result in an earlier effective date. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection The Veteran seeks service connection for bilateral wrist disabilities and a left shoulder disability. Specifically, in October 2001, the Veteran filed a claim for service connection for arthritis of bilateral wrists and left shoulder. Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre- existing such service, was aggravated during service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). The first question that must be addressed, therefore, is whether incurrence of a chronic wrist or left shoulder disorders is factually shown during service. The Board concludes it was not. The service treatment records are absent complaints, findings or diagnoses of a right wrist, a left wrist, or a left shoulder disorder during service. On the clinical examination for separation from service, the Veteran's upper extremities were evaluated as normal. On the Report of Medical History completed by the Veteran in conjunction with his separation examination, he denied ever having swollen or painful joints, arthritis, painful or "trick" shoulder or ever having an illness or injury other than those already noted. Thus, there is no medical evidence that shows that the Veteran suffered from a chronic wrist or left shoulder disorders during service. As for statutory presumptions, service connection may also be established for a current disability on the basis of a presumption under the law that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C.A. §§ 1112, 1131 and 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307 and 3.309(a). Arthritis can be service-connected on such a basis. However, there are no records in the claims file that show right or left wrist arthritis or left shoulder arthritis within one year of the Veteran's discharge from service. The first showing of arthritis in the record is not until many years after the appellant's discharge from service. The record indicates that the Veteran presented as a new patient in April 2001 to the Gaylord Clinic and advised that he had previously been to Detroit VA clinic about 20 years before. The Veteran also noted that he was followed by a private physician and a private dermatologist. The Veteran reported a history of osteoarthritis. X-rays taken in April 2004 of both wrists showed mild osteoarthritis involving the radial carpal joint space bilaterally as well as the base of the thumbs bilaterally. X-rays taken of the left shoulder showed that bony structures, joint spaces, and soft tissues were within normal limits. X-rays taken in December 2009 of the left shoulder showed mild degenerative osteoarthritis and mild degenerative changes of the left glenohumeral joint. Alternatively, when a chronic disease is not present during service, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of continuity of symptomatology. Such evidence is lacking here. With respect to the Veteran's wrists, although the Veteran reports continuity of post-service symptoms, the Board finds his allegations to be of limited probative value. In adjudicating a claim, including as to continuity of symptomatology, the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board also has a duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Although the Veteran asserts that his wrist disorders are related to service, he is not competent to provide an opinion requiring medical knowledge, such as a question of medical causation. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). He is competent to give evidence about what he experienced; for example, he is competent to report that he engaged in certain activities in service and currently experiences certain symptomatology. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). Competency, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Board acknowledges that it cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). However, such lack of contemporaneous evidence is for consideration in determining credibility. In this regard, the Board notes that the record is devoid of objective evidence of wrist pain or arthritis until decades after service. In April 1970, the Veteran underwent VA examination. There was no documentation of any complaints. The Veteran reported that he had a piece of shrapnel removed from right eye in July 1969 that had left hardly any residuals except seeing spots before eyes at times. The Veteran also reported history of malaria and appendectomy. At that time, the Veteran's musculoskeletal system was essentially negative. Only a well- healed appendectomy scar was noted. The Board also notes that in 1970, 1974, and 1984, the Veteran filed claims with VA for disability benefits for malaria, right eye condition, appendectomy, ringworm, left knee injury evidencing his awareness that he could apply for VA benefits for service-related disabilities. At that time he did not file a claim for service connection for wrist pain or arthritis. This is inconsistent with his current assertion that his wrist pain has existed since service because it is reasonable to conclude that if he believed that he had wrist pain or arthritis in 1970, 1974, or 1984 that was related to service, he would have claimed service connection for it at that time. As such, the Board finds that any assertions by the Veteran as to the continuity of symptomatology of his bilateral wrist disorders since service to be less than credible. With respect to the Veteran's left shoulder, at the December 2009 VA examination, the Veteran stated that his left shoulder started to bother him in the late 1970s - 1978 or 1979, sometime in there. Thus, in light of the clear denials from the appellant of continuity of symptomatology, and the lack of any relevant history reported between the Veteran's date of discharge in 1970 and the late 1970s, service connection is not warranted under 38 C.F.R. § 3.303(b). When a disease is first diagnosed after service, service connection can still be granted for that condition if the evidence shows it was incurred in service. 38 C.F.R. § 3.303(d). To prevail on the issue of service connection there must be medical evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet App. 341, 346 (1999). In this case, the appellant clearly has current wrists and left shoulder disabilities. The remaining question, therefore, is whether there is medical evidence of a relationship between the current disability and military service. In a statement received in December 2002, the Veteran stated that a fall from a helicopter while attempting to retrieve killed and injured troops caused injury to his shoulder and wrists. In a statement received in August 2003, the Veteran stated, "Back, in 1969 I went on a mission to help get two dead GI fellow K-75 Range[r]s LURPS out of the field. They had been shot to death by the Viet Cong. I was a team leader and we flew in by chopper, I had gotten off the wrong side of the chopper and fell approx[imately] 15 feet off of the rung of the chopper. I had the radio/full pack, M-66 and 79 launcher, on my back when I went down and took a full impact on the ground." The Veteran stated that he believed the fall from the chopper caused all of his "late" problems including arthritis in his wrists and left shoulder. On his VA Form 9, Appeal to the Board of Veterans' Appeals, the Veteran stated, "... I received treatment in Vietnam after exiting the helicopter at a height of approximately 15 [feet] with a full pack and radio equipment." In December 2004, the Veteran stated that he fell out of helicopter several feet and came down and hit the ground with his knee and his hands/wrists and was carrying a radio on his back. The Veteran stated that he believed the impact from hitting the ground from 15 feet caused arthritis, that x-rays taken at VA show arthritis in his wrists and shoulder, that he has had trouble with pain in both his wrists since his time in Vietnam, and that he had gone to the doctor years ago regarding his shoulder. In a September 2006 letter, the Veteran stated that in 1969 when he was in Vietnam, he was on a mission to help retrieve two dead K-75 rangers LRRPS in his company and that he fell out of chopper 12/15 feet and landed on his left knee. In a January 2007 Written Brief Presentation, the Veteran's representative stated, "The Veteran contends he injured his wrists and shoulder when he fell out of a chopper while in Vietnam." In May 2007, VA received a copy of the cover sheet and pages one and ten of the February 2007 Board decision that denied, inter alia, service connection for a chronic left shoulder disorder. The Veteran's handwritten statement on the cover page noted, "They have not proved that this did not happen in Vietnam. I say that this is what cause[d] it [and] they say not so." In December 2008, the Veteran stated that he was diagnosed with arthritis in his shoulder several years prior, and that he stood behind his position that his problem was caused by the fall out of a helicopter in Viet Nam in 1969 during combat. In the case of any Veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, campaign, or expedition, the Secretary shall accept as sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the Veteran. Service- connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b) (West 2002). The record clearly shows that the Veteran engaged in combat with the enemy while in Vietnam. He is the recipient of a Purple Heart and sustained a shrapnel injury as a result of combat. However, at the December 2009 VA examination, the Veteran stated that he fell 12-14 feet out of a helicopter with a big radio on his back. He landed on his outstretched hands and left knee. His shoulder did not bother him at that time. His left shoulder started to bother him in the late 1970s. He stated that he does not know why his shoulder started to bother him as there was no specific injury. The Veteran stated that he began having pain in both shoulders, that he saw a doctor, and that x-rays taken showed arthritis in the right shoulder but none in the left shoulder. The Veteran stated that the only thing he could think of was that he took a big impact when he fell out of the helicopter but that he did not actually fall on the shoulder. Although the Veteran's lay statements regarding a left shoulder injury he suffered would under normal conditions be accepted as credible, his statements have been internally inconsistent. Although the Veteran originally alleged that he injured his left shoulder in service when he fell from a helicopter, he reported at the December 2009 VA examination that his shoulder did not bother him at the time that he fell out of the helicopter or for years later. The Veteran's statements during the December 2009 VA examination coupled with the lack of documentation of in- service left shoulder injury and a normal upper extremity examination at separation are credible evidence that a left shoulder injury did not occur during the Veteran's military service. Thus, the Board cannot accept as credible the Veteran's earlier statements that he injured his left shoulder in service. In addition, any medical opinion based on the Veteran's assertion that he injured his left shoulder in service, is not probative. An assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. Indeed, the courts have provided guidance for weighing medical evidence. They have held, for example, that a medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran underwent VA examination in April 2004. The Veteran reported that he dove approximately 15 feet off a helicopter, that medical treatment at that time included crutches for four weeks, light duty and then return to active duty. After physical examination of the Veteran, the examiner, Dr. Nowaczyk, diagnosed mild osteoarthritis of the bilateral radio carpal joint of both wrists. The examiner opined that the Veteran's complaints of left shoulder and bilateral wrists were not likely related to service-connected injury. In an August 2004 Addendum, Dr. Nowaczyk indicated that the claims file had been reviewed and that there was no change in her medical opinion given regarding the Veteran's claim for service connection for, inter alia, left shoulder and bilateral wrist conditions. The Board notes that the parties to the JMR agreed that the April 2004 VA examination report was inadequate because the opinions were not supported by a complete rationale. The Board remanded the case in September 2008 to afford the Veteran a VA examination. The Board directed that it had accepted as credible the Veteran's reports of a left shoulder injury in service as the Remand was issued prior to the Veteran's statement that he did not injure his left shoulder in service. In January 2009, the Veteran underwent VA examination. He reported date of onset of left shoulder condition 1970 and description of circumstances and initial manifestation of injury a 1969 fall. After review of the claims file, examination and interview of the Veteran, the VA examiner, Dr. Sutton, diagnosed left shoulder strain and opined that the left shoulder strain was at least as likely as not to be related to the service based on the available information including the Board accepting the Veteran's reports. As Dr. Sutton's opinion was based on an incorrect factual premise, it is not probative. The Veteran again underwent VA examination in December 2009. The Veteran stated that he fell 12 to 14 feet out of helicopter with a big radio on his back, that he landed on his outstretched hands and left knee, that his shoulder did not bother him at that time. The Veteran reported that his left shoulder started to bother him in the late 1970s - 1978 or 1979, sometime in there, and that he did not know why his shoulder started to bother him as there was no specific injury. The Veteran reported that he began having pain in both shoulders, that he saw a doctor, and that x-rays were taken. The Veteran reported that he had arthritis in the right shoulder but none in the left shoulder. The Veteran stated that he still had pain in his left shoulder and the only thing he could think of was that he took a big impact when he fell out of the helicopter. The Veteran reported that he did not actually fall on the shoulder. After review of the claims file, interview and physical examination of the Veteran, the examiner, Dr. Kimovec, diagnosed mild generative changes of the glenohueral joint left shoulder. Dr. Kimovec opined that mild degenerative changes of the left glenohumeral joint were not caused by or a result of active duty military service. Dr. Kimovec explained that the Veteran was not seen for nor treated for a shoulder condition while in the military, that his separation examination was silent for a shoulder condition, and that he was not treated for it one year after discharge. The examiner noted that the Veteran had mild arthritic changes seen in both shoulders, not just the left shoulder, that it was not unusual for a person of the Veteran's age to have arthritic changes in the shoulders, and that it was part of the normal aging process. The Board notes that there is a difference of opinion among the medical professionals. In deciding whether the Veteran's left shoulder disorder was incurred in or aggravated by his active duty service, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Evans v. West, 12 Vet. App. 22, 30 (1998). That responsibility is particularly onerous where medical opinions diverge. At the same time, the Board is mindful that it cannot make its own independent medical determinations and that there must be plausible reasons for favoring one medical opinion over another. Id. An assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. The courts have provided guidance for weighing medical evidence. They have held, for example, that a post-service reference to injuries sustained in service, without a review of service medical records, is not competent medical evidence. Grover v. West, 12 Vet. App. 109, 112 (1999). Further, a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). In addition, an examination that does not take into account the records of prior medical treatment is neither thorough nor fully informed. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). A bare transcription of lay history, unenhanced by additional comment by the transcriber, is not competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). Moreover, a medical professional is not competent to opine as to matters outside the scope of his expertise. Id. citing Layno v. Brown, 6 Vet. App. 465, 469 (1994). A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Also, a medical opinion is inadequate when unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Finally, as stated above, a medical opinion based on an inaccurate factual premise is not probative. Reonal, 5 Vet. App. at 461. In sum, the weight to be accorded the various items of medical evidence in this case must be determined by the quality of the evidence and not necessarily by its quantity or source. In this case, as noted above, Dr. Sutton's January 2009 VA medical opinion was based on an inaccurate factual premise and is, therefore, not probative. In comparison, Dr. Kimovec based her December 2009 decision on a review of the claims file which showed no treatment for a left shoulder injury and a separation examination that was silent for a shoulder condition as well as the Veteran's statements of no left shoulder injury in service. Thus, the Board finds that Dr. Kimovec provided an opinion based on the medical evidence of record, and supplied a detailed rationale outlining the medical evidence that the Veteran's left shoulder injury was not caused by or the result of his active duty service. Therefore, Dr. Kimovec's December 2009 VA medical opinion has been accorded high probative weight. With respect to the Veteran's wrists, the Board accepts as credible the Veteran's statements that he injured his wrists when he fell out of the helicopter. However, that an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. In April 2007, a letter authored by Dr. Wittenburg states, ... you reported an injury in 1969 in Vietnam when you fell about 15 feet out of helicopter. You also had injured your knee at that time and both of your wrists. Since that time, you have had aching pain which is chronic in nature. You stated that you take Naproxen 500 mg, p.o., and b.i.d. which seems to help. You are able to remain function and active but do have some chronic intermittent aching pain, especially if not taking the Naproxen. Presently, you have full range of motion of your wrists with 5/5 grip strength. You are neurovascularly intact with [no] numbness and tingling in your fingers. You have negative Tinel's. Nontender presently and no thenar atrophy although both of your hands are thin bilaterally. I did obtain x-rays of both wrists, three view x-rays which reveals evidence of bilateral STT degenerative arthritis. No fracture or mass is noted on these films. The radial carpal joint looks okay and the CMC joint does as well, but the STT arthritis is obvious on both sides. There is no obvious fracture although there may have been a nondisplaced fracture which is had to tell, again there is no evidence of a fracture. I had a long discussion with you about your STT joint arthritis at both wrists. I think that certainly this could be related to the impaction injury from the helicopter fall in 1969. I cannot know for sure but I do think that this is the cause of your present symptoms. ... In January 2009, Dr. Sutton noted that the claims file was reviewed and that the Veteran reported that he fell from a helicopter in 1969 and has had pain in both wrists since then. After physical examination of the Veteran, Dr. Sutton diagnosed bilateral wrist strain and opined that the bilateral wrists strain conditions were at least as likely as not to be related to the service based on the available information including the Board accepting the Veteran's reports. Dr. Sutton also stated that he could not relate any other conditions of the wrists other than the strain without resorting to speculation. In December 2009, Dr. Kimovec noted that the claims file was reviewed. The Veteran reported that while in Vietnam, he fell out of a helicopter and came down on his wrists with his hands outstretched. When he got out of the field that same day, he saw a doctor and he says that they did not do much about his wrists because they were concentrating on his knees. The Veteran reported that his wrists have always ached but he had not seen anyone for it until recently. The Veteran reported that he saw a doctor in 2007 and x-rays were taken which showed that both wrists had arthritis. After physical examination of the Veteran, Dr. Kimovec diagnosed mild degenerative changes bilateral wrists and opined that the mild degenerative changes bilateral wrists were not caused by or a result of active duty military service. Dr. Kimovec explained that the Veteran was not seen for nor treated for a bilateral wrist condition while in the military, that the separation examination was silent for a wrist condition, and that the Veteran was not treatment for a wrist condition within one year after discharge. She also noted that the Veteran had mild arthritic changes in both wrists, that it was not unusual for a person of the Veteran's age to have arthritic changes in the wrists, and that this was part of the normal aging process. Again, there is a difference of opinion among the medical professionals. In this case, the Board places greater weight on Dr. Kimovec's December 2009 unfavorable VA opinion than it does on Dr. Wittenburg's and Dr. Sutton's favorable medical opinions. With respect to Dr. Wittenburg's April 2007 opinion, a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). In this case, Dr. Wittenburg states that he thinks that the Veteran's STT joint arthritis could be related to the impaction injury from helicopter fall in 1969 and that he thinks that this is the cause of the Veteran's present symptoms, but he does not provide any rationale of why he thinks so. In addition, Dr. Wittenburg's opinion unfortunately fails to take into account the relevant service medical records on file which document the normal evaluation for the Veteran's upper extremity at separation as well as the gap of more than thirty years between the Veteran's discharge from service and his first documented complaints of wrist pain. Similarly, although Dr. Sutton claims to have reviewed the Veteran's claims file, his opinion does not take into account the records of prior medical treatment and does not provide supporting clinical data or other rationale. Dr. Sutton stated that he could not relate any other condition than strain without resorting to speculation. In comparison, Dr. Kimovec's December 2009 opinion was rendered after a review of the claims file, including the Veteran's pertinent medical records and history. Thus, the Board finds that the VA examiner's December 2009 reasoned medical opinion is accordingly more probative than either statement by Dr. Wittenburg or Dr. Sutton. In February 2010, the Veteran asserted that the January 2010 VA medical examination and opinion are inadequate as a matter of law and noted that the examiner who provided the opinion based his opinion on the absence of service medical records documenting the injuries during service and that in rendering such an opinion, the examiner failed to appreciate the fact that the Veteran was a combat Veteran and thus entitled to the application of 38 U.S.C. § 1154(b). In October 2010, the Veteran again argued that the January 2009 VA examiner's opinion had more probative value than the December 2009 VA examiner's opinion because the December 2009 VA examiner, Dr. Kimovec failed to consider that the Veteran was a "combat Veteran." The Veteran stated, "Dr. Kimovec's opinion is inadequate in that it did not acknowledge [the Veteran's] status as a combat Veteran and assumed that his report of an in-service injury required substantiation." Dr. Kimovec explained that the Veteran was not seen for nor treated for a bilateral wrist condition while in the military, that the separation examination was silent for a wrist condition, and that the Veteran was not treated for a wrist condition within one year after discharge. She also noted that the Veteran had mild arthritic changes in both wrists, that it was not unusual for a person of the Veteran's age to have arthritic changes in the wrists, and that this was part of the normal aging process. Thus, she does not base her opinion on the absence of service medical records documenting the injuries during service, rather she bases her opinion on the absence of service medical records documenting complaints or treatment of a wrist condition in addition to the absence of a wrist condition at separation and her medical knowledge of the normal aging process. In fact, she notes the pertinent evidence used as "Separation exam 2/6/70: Normal exam; Veteran's history form does not include any problem with wrists, shoulders, or knees." Dr. Kimovec also noted that the Veteran reported that he fell out of helicopter and came down on his wrists with his hands outstretched and that he saw a doctor but they did not do much about his wrists because they were concentrating on his knees. Dr. Kimovec noted that the Veteran reported that his wrists have always ached but he had not seen anyone for it until recently. Nowhere in her opinion does she dispute the actual injury. Thus, the Board finds unpersuasive the Veteran's contention that the December 2009 VA examination and opinion are inadequate. Therefore, the weight of the competent and probative medical evidence preponderates against a finding that the Veteran's current bilateral wrist disorder is related to his active duty service. A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) [service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service]. In this case, the medical evidence does not show treatment or diagnosis of a right wrist, a left wrist, or a left shoulder disorder until many years after service. The Veteran did not begin to state he had experienced wrist or left shoulder symptoms until after he filed his claim for VA compensation in October 2001. Thus, the record is absent credible evidence of in-service incurrence of a left shoulder injury, evidence of wrist or left shoulder arthritis within a year following service, and credible evidence of continuity of symptomatology. Further, the Board finds more probative the unfavorable medical opinion of Dr. Kimovec that the Veteran's left shoulder and wrists disorders are not likely related to his active duty service than the other medical opinions of record. Although the Veteran contends that his wrists disorders and left shoulder disorder are related to his service, as a layman he is not competent to offer opinions on medical causation and, moreover, the Board may not accept unsupported lay speculation with regard to medical issues. Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). Accordingly, the Board concludes that the preponderance of the evidence is against the claims for service connection, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. Earlier Effective Date The Veteran seeks an effective date earlier than April 24, 2007, for the grant of service connection for PTSD. The effective date for a grant of direct service connection will be the day following separation from active service, or the date entitlement arose if a claim is received within one year after separation from service. Otherwise, the effective date is the date of receipt of claim or date entitlement arose, whichever is later. 38 U.S.C. 5110(a); 38 C.F.R. § 3.400. Unless specifically provided, the effective date will be assigned on the basis of the facts as found. 38 C.F.R. § 3.400(a). A specific claim in the form prescribed by the Secretary of Veterans Affairs must be filed in order for benefits to be paid to any individual under the laws administered by VA. 38 C.F.R. § 3.151(a) (2010). The term "claim" or "application" means a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief of entitlement, to a benefit. 38 C.F.R. § 3.1(p) (2010). "Date of receipt" generally means the date on which a claim, information or evidence was received by VA. 38 C.F.R. § 3.1(r). The Veteran's original claim for service connection for PTSD was received on April 24, 2007. On the VA Form 21-4138, Statement in Support of Claim, he noted that he had been treating at the VA OPC in Gaylord and had symptoms of PTSD and was scheduled to see a counselor in May 2007. The Veteran requested consideration for additional benefits due to PTSD. After a thorough review of the claims folder, the Board finds that the Veteran's VA Form 21-4138 that served as the basis for the award of service connection for PTSD was received on April 24, 2007. Considered as an original claim for service connection for PTSD, it was received more than one year after the Veteran's date of separation from service. Accordingly, the applicable regulation for a claim for service connection received more than one year after the date of separation from service dictates that the effective date is the date of receipt of the claim, or the date entitlement arose, whichever is the later. Therefore, the appropriate effective date is the date of receipt of the claim, April 24, 2007. Prior to April 24, 2007, there is no communication of record from the Veteran or any representative or other party to VA that would constitute a claim for service connection for PTSD. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against an effective date earlier than April 24, 2007, for the award of service connection for PTSD, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. The effective date for service connection based on an original claim cannot be any earlier than the date of receipt of claim. As the preponderance of the evidence is against the claim, the Board finds that an effective date earlier than April 24, 2007, for the award of service connection for PTSD is not warranted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER 1. Entitlement to service connection for a chronic right wrist disorder to include arthritis is denied. 2. Entitlement to service connection for a chronic left wrist disorder to include arthritis is denied. 3. Entitlement to service connection for a chronic left shoulder disorder to include arthritis is denied. 4. Entitlement to an effective date earlier than April 24, 2007, for the award of service connection for PTSD, is denied. REMAND With respect to the Veteran's claim for increased rating for his service-connected PTSD, it does not appear that any attempt has been made to obtain the Veteran's treatment records from the Vet Center in Florida. The January 2010 VA examiner noted that the Veteran had individual psychotherapy and medication monitoring services specific to PTSD at the Vet Center in St. Petersburg, Florida from November 24, 2008 to March 4, 2009 and that the primary therapist was identified as Mr. B., Master Social Worker. These records are very significant in view of the fact that Mr. Bailey's assessment of the Veteran is contradictory to the assessments of record. As noted above, the Veteran reported that he spends half of the year in Florida and half of the year in Michigan. The record indicates that the Veteran presented for psychiatric consultation on October 9, 2008 in Florida, thus, the Board find that efforts should be made to obtain his mental health records from Vet Center since that date. In addition, the Veteran has submitted a private psychosocial assessment dated in September 2010 which appears to indicate a material change in the severity of the Veteran's service- connected PTSD since he was last examined. Thus, in order to afford the Veteran every consideration with respect to the present appeal and to ensure due process, it is the Board's opinion that an additional VA medical examination should be conducted to assess the current severity of the Veteran's PTSD. 38 C.F.R. § 3.159(c)(4). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be requested to indicate if he has received any VA or non-VA medical treatment for his PTSD that is not evidenced by the current record. If so, the Veteran should be provided with the necessary authorizations for the release of any treatment records not currently on file. These records, as well as records from Vet Center in St. Petersburg from November 2008 to the present, should then be obtained and associated with the claims folder. The Veteran should be advised that he may also submit any evidence or further argument relative to the claim at issue. 2. The Veteran should be afforded an additional VA examination to ascertain the current severity of his PTSD. The claims file must be made available to and reviewed by the examiner in conjunction with the examination, and the examination report should reflect that such a review was made. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. The examiner should offer an opinion as to whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent), that the veteran's PTSD causes him to be unable to obtain and retain substantially gainful employment. 3. The case should be reviewed on the basis of the additional evidence. If the benefit sought is not granted in full, the Veteran should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. No action is required of the appellant until further notice. However, the Board takes this opportunity to advise the appellant that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claim. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The appellant is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. The appellant has the right to submit additional evidence and argument on the matter or matters 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 that are 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. 2008). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs