Citation Nr: 1120743 Decision Date: 05/27/11 Archive Date: 06/06/11 DOCKET NO. 09-41 077 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Whether new and material evidence to reopen a claim for service connection for recurrent subluxation, right shoulder, has been received. 2. Whether new and material evidence to reopen a claim for service connection for recurrent subluxation, left shoulder, has been received. 3. Entitlement to service connection for carpal tunnel syndrome, right hand (claimed as a hand condition). 4. Entitlement to service connection for carpal tunnel syndrome, left hand (claimed as a hand condition). 5. Entitlement to service connection for a right elbow disorder. 6. Entitlement to service connection for a left elbow disorder. 7. Entitlement to service connection for a cervical spine disorder. 8. Entitlement to service connection for a lumbar spine disorder. 9. Entitlement to service connection for fibromyalgia. 10. Entitlement to service connection for skin problems due to shaving. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs ATTORNEY FOR THE BOARD S. Layton, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from November 1979 to January 1980. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision by the Milwaukee, Wisconsin Regional Office (RO) of the Department of Veterans Affairs (VA). FINDINGS OF FACT 1. In a decision dated July 1980, the RO denied the Veteran's claim of service connection for subluxation and pain in the joints of his shoulders bilaterally. The Veteran did not appeal this determination, and it became final. 2. Evidence associated with the claims file since the July 1980 decision is cumulative and redundant of evidence of record at the time of the prior denial, does not relate to unestablished facts necessary to substantiate the claim for service connection for a disability manifested by subluxation and pain in the joints of the shoulders bilaterally, and does not raise a reasonable possibility of substantiating the claim. 3. The Veteran does not currently have a diagnosis of carpal tunnel syndrome in his right hand. 4. The Veteran does not currently have a diagnosis of carpal tunnel syndrome in his left hand. 5. The Veteran does not have a currently diagnosed right elbow disorder. 6. The Veteran does not have a currently diagnosed left elbow disorder. 7. The weight of the competent and credible evidence of record weighs against the claim for service connection for a cervical spine disorder. 8. The weight of the competent and credible evidence of record weighs against the claim for service connection for a lumbar spine disorder. 9. The Veteran does not currently have a diagnosis of fibromyalgia. 10. The Veteran does not currently have a diagnosis of a skin disorder. CONCLUSIONS OF LAW 1. As new and material evidence has not been received, the claim for service connection for recurrent subluxation, right shoulder, is not reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2010). 2. As new and material evidence has not been received, the claim for service connection for recurrent subluxation, left shoulder, is not reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2010). 3. The criteria for service connection for carpal tunnel syndrome, right hand, have not been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 4. The criteria for service connection for carpal tunnel syndrome, left hand, have not been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 5. The criteria for service connection for a right elbow disorder have not been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 6. The criteria for service connection for a left elbow disorder have not been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 7. The criteria for service connection for a cervical spine disorder have not been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 8. The criteria for service connection for a lumbar disorder have not been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 9. The criteria for service connection for fibromyalgia have not been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 10. The criteria for service connection for a skin disorder have not been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2009), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2010), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specific to requests to reopen, a claimant must be notified of both the reopening criteria and the criteria for establishing the underlying claim for service connection. See Kent v. Nicholson, 20 Vet. App. 1 (2006). The record reflects that the Veteran was mailed a letter in February 2009 advising him of what the evidence must show and of the respective duties of VA and the claimant in obtaining evidence. This letter also provided him with appropriate notice with respect to the disability-rating and effective-date elements of his claim. Additionally, this letter also informed him of the bases for the denials of his prior claim for service connection for subluxing bilateral shoulders and informed him of what needed to be shown to successfully reopen his claim. The March 2009 rating decision reflects the initial adjudication of the claim after issuance of this letter. Hence, the February 2009 letter-which meets the content of notice requirements described in Dingess/Hartman, Pelegrini, and Kent-also meets the VCAA's timing of notice requirement. The Board also finds the Veteran has been afforded adequate assistance in response to his claims. The Veteran's service treatment records (STRs) are on file. VA Medical Center treatment records have been obtained. The Veteran has submitted additional evidence obtained from private doctors. Neither the Veteran nor his representative has identified any outstanding evidence, to include medical records, which could be obtained to substantiate the claims. VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 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, 20 Vet. App. at 83. The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. The Veteran was not afforded VA examinations for bilateral hand, bilateral elbow, fibromyalgia, or skin disorders. However, as discussed below, there is no competent and credible evidence that the Veteran has been diagnosed as having current bilateral hand, bilateral elbow, fibromyalgia, or skin disorders, and there is no competent and credible evidence of any bilateral hand, bilateral elbow, fibromyalgia, or skin symptoms that may be related to a disease or injury in service. The Veteran has not reported a continuity of bilateral hand, bilateral elbow, fibromyalgia, or skin symptomatology, there is no medical evidence that any such symptoms may be related to service, and the Veteran has not alluded to the existence of any such evidence. VA examinations are therefore not necessary. See McLendon, 20 Vet. App. at 83. In sum, the Board is satisfied that any procedural errors in the RO's development and consideration of the claims were insignificant and non prejudicial to the Veteran. Accordingly, the Board will address the merits of the claims. Law and Regulations-New and Material Evidence VA law provides that a claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2010). In determining whether evidence is "new and material," the credibility of the evidence in question must be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held, however, that evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented to the Board. Anglin v. West, 203 F.3d 1343 (2000). The Board, in the first instance, must rule on the matter of reopening a claim. The Board has a responsibility to consider whether it is proper for a claim to be reopened. Jackson v. Principi, 265 F.3d 1366 at 1369 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Recurrent Subluxation, Right and Left Shoulders In a July 1980 rating decision the RO determined that service connection was not warranted for bilateral shoulder disorders. It was noted, in essence, that the service treatment records showed that the Veteran's shoulder disorders existed prior to service, and permanent aggravation during service was not shown. The Veteran did not perfect an appeal of the decision, and it became final. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2010); 38 C.F.R. § 3.104 (2010). The evidence received since the July 1980 rating decision includes private medical records from 1999 and 2001, VA outpatient records from 2009, the report of a September 2009 VA examination, and additional statements from the Veteran. While some of the records note the Veteran's present diagnosis of bilateral acromioclavicular joint degeneration, none of the records indicate that the Veteran's preexisting bilateral shoulder disorder was permanently aggravated by his active duty, which was the basis for the prior denial. In fact, the September 2009 VA examiner specifically opined that it was less likely than not that the Veteran's bilateral acromioclavicular degeneration was either caused by or permanently aggravated beyond the normal progression of the disease by his duties in the military. Based upon a comprehensive review of the record, the Board finds the evidence added to the claims file since the July 1980 rating decision is either cumulative or redundant of the evidence of record and does not raise a reasonable possibility of substantiating the claim. The evidence added to the record does not include competent and credible evidence which demonstrates that the Veteran's current bilateral shoulder disorder was permanently aggravated beyond the normal progression of the disease by his active duty service, which were the bases for the prior determination. The medical reports reflect the Veteran's current condition, and contain an opinion which weighs against the claim. The Veteran's statements are merely redundant of the evidence previously considered. The Board does not dispute that the Veteran currently experiences symptoms relating to his bilateral shoulders. Unfortunately, there is still no competent and credible medical evidence of record which indicates that the Veteran's preexisting bilateral shoulder disorder was permanently aggravated beyond the normal progression of the disease by his active duty. As the information provided in support of the application to reopen the claims for service connection for recurrent subluxation of the right and left shoulders does not include new and material evidence, the appeal as to these issues must be denied. Law and Regulations-Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. 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, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F .3d 1331, 1337 (Fed.Cir.2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept 14, 2009). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). A disorder may be service connected if the evidence of record, regardless of its date, shows that the veteran had a chronic disorder in service or during an applicable presumptive period, and that the veteran still has such a disorder. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-95 (1997). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Bilateral Carpal Tunnel Syndrome, Bilateral Elbows, Cervical Spine and Lumbar Spine disorders, Fibromyalgia, and Skin Disorder Due to Shaving-Factual Background The Veteran's service treatment records are negative for any signs, symptoms, or diagnoses of a disorder of either hand, a disorder of either elbow, a disorder of either the cervical or lumbar spine, fibromyalgia, or a skin disorder. The January 1980 report of medical board proceedings summarized that the Veteran's only diagnosis was recurrent subluxating of both shoulders. Post-service, a July 1999 chest X-ray report from a private hospital contains a note that the Veteran had carpal tunnel syndrome. An undated history of treatment from a private hospital reflects that the Veteran had a known history of carpal tunnel syndrome bilaterally, status post surgery on the right hand in 1999. Additional private treatment records show that the Veteran underwent left and right ulnar nerve transposition and neurolysis in January and April 2001. Additionally, he had a left hand wound debridement performed by a private hospital in February 2001. VA medical center outpatient records from November 2008 through March 2009 contain the Veteran's complaints of pain in his neck, elbows, hands, and mid back. A November 2008 X-ray report from a VA medical center reflects that the Veteran had degenerative disc disease at C4 through C5 and 6. A VA physical therapy note from December 2008 contains the Veteran's complaints of pain that would start in his neck and would radiate through his bilateral shoulders and forearms as well as his mid-back. It was noted that his pain began about seven or eight months previously. The therapist observed that the Veteran had previously been a garbage man for the city government for approximately ten years and was working at that time as a Semi Truck Driver. In a January 2009 VA hospital request for a consult, a provisional diagnosis of fibromyalgia was listed. In the January 2009 consult note, the Veteran reported that his chief complaint was an acute exacerbation of fibromyalgia. The Veteran gave a long history of fibromyalgia and degenerative joint disease. He stated that he hurt all over and rated his pain as an 8 on a 0 (low) to 10 (high) pain scale. The Veteran also reported that he had bilateral carpal tunnel and sarcoidosis or fibromyalgia. He said that he could not pursue treatment because he needed to work. The examiner provided diagnoses of cocaine and alcohol dependency, depression that may be transient, and sleep disturbance. Magnetic Resonance Imaging (MRI) of the cervical spine taken in February 2009 revealed multilevel degenerative disc changes, most severely at C4 and C5 with mild retrolisthesis as well as reversal of normal cervical curvature. The MRI also showed broad-based disc protrusion at C3-4 and C4-5 with corddeformity with severe narrowing of the foramen for the left C3 nerve roots. During a VA neurosurgery outpatient consultation in March 2009, the Veteran reported pain, numbness, and tingling in his bilateral upper extremities. He complained of pain which radiated through his shoulders and down the outside of his arms to his elbows. The Veteran claimed that he had been diagnosed with fibromyalgia due to his pain symptoms. The examiner performed electromyography testing (EMG) which revealed no significant abnormalities. The examiner remarked that there was no electrodiagnostic evidence for a bilateral carpal tunnel syndrome or left C5-8 radiculopathy. The examiner opined that further EMG testing was not indicated at that time. The diagnosis was chronic neck pain and pain radiating down the elbows with a remote history of bilateral carpal tunnel releases with mild herniated nucleus pulposus without significant stenosis. On VA examination in September 2009, the Veteran reported that his low back and neck pain started about a year and a half ago. He reported no particular injury to his back or neck. He said he was not currently working due to pain. On objective observation, the examiner found no trigger points. There were tight paraspinal muscles in the cervical and lumbar region. An X-ray of the lumbar spine revealed mild degenerative changes at L1-L2, L3-L4, and L4-L5 disc levels. The examiner gave diagnoses of lumbar back degenerative disease and cervical spine degeneration. The examiner opined that the condition of lumbar degeneration was less likely than not associated with the Veteran's military service, as the Veteran had worked as a trucker and had other jobs which required repetitive range of motion over the years. Additionally, the examiner noted the Veteran's weight gain, inactivity, and muscle imbalances. The examiner also opined that the cervical spine disorder was less likely than not associated with the Veteran's military service. The examiner noted that there was no noted injury to the neck or low back while the Veteran was in the military, and the Veteran did not note his back to be a problem during the two months he was on active duty. The examiner concluded that the degeneration was more likely than not related to forces and muscle imbalances and hereditary conditions, including weight and inactivity that have led to the Veteran's condition over the years since his military service. Bilateral Carpal Tunnel Syndrome, Bilateral Elbows, Fibromyalgia, and Skin Disorder Due to Shaving-Analysis Concerning the claims for bilateral carpal tunnel syndrome, bilateral elbow disorders, fibromyalgia, and a skin disorder due to shaving, the Board finds that the present claims for service connection must fail, as there is no competent and credible medical evidence of current disabilities for which service connection can be granted. Although the Veteran has complained of bilateral hand, bilateral elbow, and other body pains, pain alone, without medical diagnosis or evidence of underlying pathology, does not constitute a disability for which service connection can be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), vacated in part and remanded on other grounds sub. nom. Sanchez-Benitez v. Principi, 239 F. 3d 1356 (Fed. Cir. 2001); see Evans v. West, 12 Vet. App. 22 (1998). Here, there is no medical evidence that Veteran has current bilateral hand, bilateral elbow, or fibromyalgia disabilities underlying his complaints of chronic pain. Although the Veteran has a documented history of bilateral carpal tunnel syndrome, he underwent surgery to have those disorders corrected prior to the filing of his present claims. Upon VA neurology testing in March 2009, there was no current evidence of bilateral carpal tunnel syndrome or radiculopathy. The Board finds the March 2009 VA outpatient record to be competent, credible evidence that the Veteran does not have current carpal tunnel syndrome or either hand or radiculopathy, as the record was created by an objective medical professional in the course of providing medical treatment. The examiner was impartially reporting the results of medical testing. Concerning the Veteran's claimed fibromyalgia, the medical record does not show that the Veteran has a confirmed diagnosis of fibromyalgia. The September 2009 VA examiner noted no trigger points. In the January 2009 VA consult request, fibromyalgia was only mentioned as a potential diagnosis (emphasis added). Upon the actual consult, although the Veteran said he had a history of fibromyalgia, the examiner did not give a diagnosis of fibromyalgia. He gave diagnoses of cocaine and alcohol dependency, depression that may be transient, and sleep disturbance. Where fibromyalgia appears elsewhere in the VA treatment records, it does not appear as a diagnosis; it appears in the Veteran's self-reporting of his history. The Veteran is certainly competent to report symptoms that he is capable of observing, such as pain, and a contemporary medical diagnosis, the medical evidence of record is negative for an actual diagnosis of fibromyalgia. Concerning the Veteran's claimed skin disorder due to shaving, the Board observes that beyond his February 2009 claim, the Veteran has made no further statement regarding this claimed disorder. In his February 2009 claim, he asserted that he received a profile for a skin condition due to shaving while on active duty, and he said that he received his health care through the VA Medical Center in Milwaukee. However, the service treatment records and VA Medical Center records are both negative for any signs, symptoms, or complaints of a skin condition. In fact, during the September 2009 VA joint examination, the examiner did not observe a skin disorder, and it was noted that the Veteran said he did not have any other medical issues. As the Veteran has sought both private and VA treatment for other medical concerns, it is reasonable to expect that a skin disorder would have been noted by at least one of the medical observers. However, no such skin disorder has been noted. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. § 1131; see also 38 C.F.R. § 3.310. Thus, where, as here, medical evidence does not establish that the Veteran has the disability for which service connection is sought, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the instant case, the claims for service connection for bilateral carpal tunnel syndrome, bilateral elbow disorders, fibromyalgia, and a skin disorder due to shaving must be denied, because the first essential criterion for a grant of service connection-evidence of a current disability upon which to predicate a grant of service connection-has not been met. Cervical Spine and Lumbar Spine Disorders-Analysis The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (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); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The Veteran has contended that he has back and neck disorders as a result of his active duty. Here, there is no indication that the Veteran has had any medical training. He has not claimed to have a degree in medicine. He has not claimed to have taken and/or completed any courses in nursing. He has not claimed to have any experience in the medical field. As such, his statements are considered lay evidence. He is competent to testify as to symptoms he is able to observe, and so his statements concerning experiencing neck and back pain are considered to be competent. However, in this particular case, the Veteran is offering his opinion regarding a medical etiology concerning inner workings of the Veteran's body that are not apparent to an untrained observer. In this case, the Veteran is not asserting that his claimed back and neck disorders are the result of a specific trauma or incident during his active duty (see September 2009 VA examination report). He also has not asserted a continuity of symptomatology since his active duty (see September 2009 VA examination report). He is asserting that symptoms that, by his report, first appeared about a year and a half previously are the result of his active duty for two months in 1979 and 1980. This is not a matter involving an immediate cause and effect, or other symptom capable of observing through the senses. This matter involves the question of a medical situation developing with no continuity of symptomatology from active service. As such, it involves a complex medical situation. Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Thus, in this particular situation, the Veteran's statements are not considered to be competent nexus evidence and are outweighed by the other evidence of record. On the other hand, the VA examiner in September 2009 reviewed the claims file, considered all of the Veteran's available service and private medical records, and provided adequate reasoning and bases for the opinion that the Veteran's current back and neck disorders were less likely than not associated with the Veteran's military service. The VA physician did not employ speculative language and opined directly on the Veteran's situation. He explained the factors that supported his opinion, and he additionally provided his opinion on the more likely etiology of the Veteran's claimed disorders. Thus, this opinion is assigned great probative value. See Madden v. Gober, 123 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board is entitled to discount the weight, credibility, and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence). As such, the Board finds that the September 2009 VA opinion outweighs the assertions of the Veteran. In summary, the evidence establishes that the Veteran's cervical and lumbar spine disorders were not present during his 1979 to 1980 active duty, within the first post-service year, or for many years thereafter, and were not otherwise shown to be related to service. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for cervical and lumbar spine disorders. Conclusion In reaching the conclusions listed above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER New and material evidence was not received to reopen a claim for entitlement to service connection for recurrent subluxation, right shoulder; the appeal is denied. New and material evidence was not received to reopen a claim for entitlement to service connection for recurrent subluxation, left shoulder; the appeal is denied. Service connection for carpal tunnel syndrome, right hand (claimed as a hand condition). Service connection for carpal tunnel syndrome, left hand (claimed as a hand condition) is denied. Service connection for a right elbow disorder is denied. Service connection for a left elbow disorder is denied. Service connection for a cervical spine disorder is denied. Service connection for a lumbar spine disorder is denied. Service connection for fibromyalgia is denied. Service connection for skin problems due to shaving is denied. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs