Citation Nr: 1223367 Decision Date: 07/05/12 Archive Date: 07/13/12 DOCKET NO. 09-11 080A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for loss of grip and tendon damage of the right upper extremity. 2. Entitlement to service connection for arthritis of the right hand. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Donna D. Ebaugh, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1943 to April 1946. This matter is on appeal from a July 2008 rating decision by the Cleveland, Ohio Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction over the appeal has remained with the RO in St. Petersburg, Florida. The Veteran testified before the undersigned in October 2010. A transcript of the hearing is of record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. At the time of his enlistment, the Veteran was observed to have multiple scars of the right forearm along with a mild flexion deformity of the fourth and fifth fingers of the right hand. 2. The competent and credible evidence fails to establish that the Veteran's preexisting 4th and 5th finger disabilities increased in severity during his active service, and that surgeries undertaken in service were to ameliorate the preexisting disability. 3. Loss of grip strength is not related to service. 4. Arthritis of the right hand was not shown within one year following service and the weight of the evidence does not show a relationship to service. CONCLUSIONS OF LAW 1. Loss of grip and tendon damage of the right upper extremity was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1154, 5103(a), 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306 (2011). 2. Chronic arthritis of the right hand was not incurred in or aggravated by active service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1154, 5103(a), 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Before addressing the merits of the issue, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in March 2008 of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. In the same letter, he also was notified of how VA determines disability ratings and effective dates if service connection is awarded. The letter accordingly addressed all notice elements and predated the initial adjudication by the AOJ/RO in July 2008. Nothing more was required. Next, VA has a duty to assist a Veteran in the development of the claim. This duty includes assisting her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2011). In compliance with its duty to assist, the RO associated the Veteran's service treatment records and private treatment records with the claims file. 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. Additionally, the Veteran was afforded a VA examination in March 2011, in accordance with the Board's January 2011 Remand. The Board acknowledges that the VA examiner did not specifically address whether the Veteran's duties aggravated his preexisting hand and/or finger disability. However, the examiner found that there was no evidence of worsening (an increase in severity) as "it relates to his military service". He added that there was actual improvement following the surgery. In other words, even assuming arguendo that the Veteran's duties in service prior to surgery worsened his hand problem, the examiner found that the surgery improved his overall condition and took it to at least baseline. Thus, the Board finds that the VA examiner substantially complied with the Remand directive. The Board notes that the United States Court of Appeals for Veterans Claims has noted that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination "more than substantially complied with the Board's remand order"). The Board also acknowledges that the March 2011 VA examiner found that the Veteran's current right hand disability was not related to service or the in-service surgeries, at least in part, due to the Veteran's admitted work history following service. The examiner noted the Veteran's report of a career in construction and stated that "with this type of work one should consider that this type of work required use of his hands." The Veteran indicated that while it is true that he worked in construction for many years, he did not actually do any physical labor. Notwithstanding the VA examiner's potential misinterpretation of the Veteran's report of employment history, the Board finds that regarding the Veteran's claim for aggravation of his right hand disability, the Veteran is not entitled to service connection because his preexisting disorder did not undergo an increase in severity during service and thus was not aggravated by service. Any misinterpretation by the VA examiner regarding Veteran's post-service work history is immaterial. Regarding the claim for service connection of arthritis, the examiner concluded that the Veteran has rheumatoid arthritis in the right hand which is an autoimmune disease and not associated with surgery. Therefore, again, any discussion regarding work history is immaterial. The misinterpretation is nonprejudicial. Next, the Veteran was afforded the opportunity to testify before the Board in October 2010. In Bryant v. Shinseki, 23 Vet.App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) recently held that 38 C.F.R. 3.103(c)(2) (2010) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the undersigned essentially elicited testimony necessary to determine the nature of the Veteran's disability. In addition, the undersigned sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Transcript (T) page 12. Specifically, the undersigned explained that the Veteran needed to show evidence of aggravation of the preexisting disability in order for service connection to be warranted as well as evidence that the current arthritis is related to service. T. pages 12, 14. The undersigned held the record open for 60 days in order to allow the Veteran to submit the relevant medical opinions related to his disorder. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor has identified any prejudice in the conduct of the Board hearing. By contrast, the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for benefits. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claims based on the current record. After a careful review of the file, 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). Based on the foregoing, the Board finds that no additional assistance is required to fulfill VA's duty to assist. 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). Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2011). However, continuity of symptoms is required where a condition in service is noted but is not, in fact, chronic or where a diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b) (2011). Further, service connection may also 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. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d) (2011). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004) (citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); Caluza v. Brown, 7 Vet. App. 498, 505 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table)). In addition to the regulations cited above, service connection for certain diseases, such as sensorineural hearing loss and arthritis, may also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2011). a. Aggravation of Preexisting Disorder - Loss of Grip Strength In addition to the regulations cited above, where a veteran served during a period of war or during peacetime service after December 31, 1946, he or she is presumed in sound condition except for defects noted when examined and accepted for service. 38 U.S.C.A. §§ 1111, 1137 (West 2002). A veteran who, during peacetime, served for at least six months or after December 31, 1946 is presumed to have been in sound condition when examined, accepted and enrolled in service, except for defects noted at the time of entrance, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111, 1132, 1137 (West 2002); 38 C.F.R. § 3.304(b); see also Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004) (holding that VA, rather than the claimant, bears the burden of proving that a disability preexisted service and was not aggravated therein). According to 38 C.F.R. § 3.304(b), the term "noted" denotes only such conditions that are recorded in examination reports. A history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. 38 C.F.R. § 3.304(b)(1); Crowe v. Brown, 7 Vet. App. 238 (1994). A preexisting injury or disease will be presumed to have been aggravated in service in cases where there was an increase in disability during service. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306(b) (2011). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. This includes medical facts and principles that may be considered to determine whether the increase is due to the natural progression of the condition. However, it is crucial to note that, unlike the aggravation prong of the presumption of soundness, the veteran bears the burden of showing a worsening of the condition in service. See Wagner. It is only after a worsening is shown that the burden shifts back to VA to rebut the presumption of aggravation. Id. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. Id. However, the increase need not be so severe as to warrant compensation. Browder v. Derwinski, 1 Vet. App. 204, 207 (1991). The U.S. Court of Appeals for Veterans Claims has held that "temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered aggravation in service unless the underlying condition, as contrasted to symptoms, is worsened." Crowe v. Brown, 7 Vet. App. 238, 247-48 (1994); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Moreover, in Verdon v. Brown, 8 Vet. App. 529 (1996), the Court held that the presumption of aggravation does not attach even where the pre-existing disability has been medically or surgically treated during service and the usual effects of treatment have ameliorated disability so that it is no more disabling than it was at entry into service. The presumption of aggravation applies only when pre-service disability increases in severity during service. Beverly v. Brown, 9 Vet. App. 402, 405 (1996); Browder v. Derwinski, 1 Vet. App. 204, 206-207 (1991). Further, the usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars, absent or poorly functioning parts or organs, will also not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1). In this case, the Veteran's March 1943 service entrance examination indicated that the Veteran had a mild flexion deformity of the 4th and [sic] finger. The examination report also noted multiple scars on the right forearm. Given the notations on the service entrance examination, the Board finds that a right hand disability preexisted service and the presumption of soundness does not apply. As such, the Veteran claims that his preexisting disability increased in severity during service and was aggravated by service. Specifically, he has offered sworn testimony that he initially served as a radio operator but that his fourth finger kept getting in the way of the buttons, due to his pre-existing trigger finger disorder. Transcript [T.] page 4. He reported that surgery was undertaken to correct the fourth finger trigger finger but that for some unknown reason, the effect of the surgery was a seemingly shorter tendon. T. page 5. Following the surgery, his duty was changed to a company clerk. Id. He also testified that he entered service with trigger finger but separated from service with a claw. T. page 9. Thus, the question becomes whether the Veteran's preexisting right hand disability increased in severity during service. Service treatment records indicate the Veteran underwent two surgeries while on active duty to ameliorate the right hand disorder, in February 1944 and June 1944. There are no actual references to problems or complaints related to the hand. Rather, admission slips dated in February refer to the Veteran as undergoing corrective surgery. He was always noted to fit for active duty. A report dated in March 1944 noted that the Veteran underwent plastic repair of a contracture of right 4th and 5th fingers in February 1944. A February 1944 progress note following the surgery noted that the Veteran was moving his fingers well, had considerable power in flexion, and flexion contracture was completely corrected. A March 1944 examination for overseas duty indicated noted that the Veteran had some adherence of tendons and hyperextension of the 4th finger. Notably, he was found fit for overseas duty. A contemporaneous Clinical Record Brief referenced the Veteran's hand condition as "improved". Next, hospital treatment records indicate that the Veteran underwent plastic repair of deformity of the right 4th finger in June 1944. He was admitted in June 1944 due to hyperextension and locking of the proximal phalangeal joint, right 4th finger, related to an injury that was incurred in December 1936 in a fall through a plate glass door. A June 1944 physical examination report noted that the Veteran had little if any weakness to flexion of the hand even though there was marked contracture of the hand. The examination report also noted there was no pain or loss of strength. Progress notes following the surgery, dated in June and July 1944, indicated that the Veteran's finger was healing well. A July 1944 note indicated that the Veteran's fitness for duty was unchanged and he was still qualified for overseas duty. Improvement in the overall condition was again noted by the treating physician. Service hospital records indicate that the Veteran was treated at a station hospital for a period in October and November 1944 and then transferred to another service hospital in November 1944. The October 1944 consultation report contained an opinion that the Veteran had extensive scarring on the right forearm with limitation of function of the fingers. Hospital reports from both the transferring hospital and receiving hospital, dated in November 1944, indicated a diagnosis on admission of contracture muscle, flexors of the 3rd, 4th, and 5th fingers, right, following injury incurred in a fall through a plate glass door in December 1936. Both reports indicated that the injury was not incurred in the line of duty. A final summary from the October 1944 admitting hospital (station hospital) addressed the Veteran's complaints of difficulty in use of the 3rd, 4th, and 5th fingers on his right hand. The summary noted that physical examination revealed a mild contracture of the 3rd, 4th, and 5th fingers of the right hand as well as multiple scars on the right forearm and the fingers. Following discussion of the right hand disability as well as a disability not currently on appeal (pes planus), it was recommended that the Veteran be put on substandard duty. An October 1944 progress note from the station hospital noted the flexion contracture of the fingers and that the disability had been operated on in service. Significantly, the physician indicated that the operation had resulted in some improvement. Another October 1944 progress note from the station hospital also recorded the Veteran's complaints of contracture of the 3rd, 4th, and 5th fingers of the right hand and noted that there were no complaints of pain. The physician noted that examination revealed contraction of the muscle of the right forearm resulting in flexion deformity of 3rd, 4th, and 5th fingers and partial radial nerve injury on the side. The diagnosis was contracture of the muscle of the right forearm and a flexion deformity of 3rd, 4th, and 5th fingers secondary to the muscle contracture. An August 1945 hospital admission report for a separate shoulder injury, also noted that the Veteran had a slight flexion deformity of the 4th and 5th fingers on the right hand. A November 1945 treatment record recorded a history that the Veteran sustained an injury 10 years prior by putting his arm through a window. The author noted marked scar tissue contraction of the right forearm. The letters "L.O.D. E.P.T.I." follow the notation indicating both line of duty and existed prior to induction. The April 1946 separation examination indicated that the right hand surgery was in reference to a preexisting disability that was not incurred in the line of duty. That examination report also included a check mark ("x") that the pre-existing hand disability had been aggravated by service. An undated service treatment record noted that the Veteran had a severe laceration to his upper forearm in December 1936 and was hospitalized at that time for two months. A history of two operations was also noted. The physician noted that while in the hospital the Veteran developed contracture of 5th, 4th, and to a lesser extent, the 3rd fingers in the right hand. He had numbness to the last two fingers but that it disappeared after the second operation. It was reported that the condition had been static for six years. Notably, upon discharge from service, the Veteran filed a claim for service connection for the right hand disability and underwent a VA examination in October 1947. At that time, he complained of hyperextension of the interphalangeal joint of the right 4th finger. He also reported that he was unable to fully extend the right index finger. He reported that there was a full feeling within the cicatrix of the ulnar aspect of the right forearm middle portion. He also reported that following the February 1944 surgery, there was not much change in the 4th digit. Importantly, the examiner noted that there was some improvement for some time. Then, gradually, the Veteran noted loosening of the action in the 4th finger and more hyperextension and locking of the finger. On physical examination, the examiner noted that the Veteran was able to make a fist and the flexion powers were good except for the little finger, which was diminished by approximately 20 percent. Extension of the fingers was not performed well. The index and second fingers could not be extended rapidly. On continued application, they were extended but at the expense of having the ring finger go into hyperextension. Closing of the hand was somewhat delayed. Extensor power of the ring, second and little fingers was not impaired although the ring finger was reduced in power about 25 percent. There was neither abduction nor adduction in the little fingers. There were also sensory changes in the right hand, including a tingling sensation over the Veteran's scar. The diagnosis was deformity of the right ring finger manifested by hyperextension and locking of proximal interphalangeal join due to injury incurrence in December 1936 when cut on a plate glass door prior to entrance to service. The examiner also diagnosed persistence of deformity right ring finger following surgical repair of deformity and following tendon lengthening of flexors to ring and little fingers with minimal disability as well as flexion contracture, mild of interphalangeal joints, right second finger with minimal disability. The Board has considered the Veteran's contention that his service duties worsened his preexisting trigger finger such that surgery was required. First, while he is competent to recall various symptoms such as pain and loss of range of motion, the Board finds the Veteran is not competent to assess whether his disability was worsened during his active service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, even if the Veteran is correct and his disability worsened for a time, the evidence does not demonstrate an increase in severity of the disability overall in service. Further, if the surgery in service had an ameliorating effect, it will not be considered service connected unless the disease or injury is otherwise aggravated by service. As noted above, service treatment records indicate that the Veteran's right hand disability improved at times during service. Significantly, as noted above, the February 1944 progress note following the surgery noted that the Veteran was moving his fingers well, had considerable power in flexion, and flexion contracture was completely corrected. Likewise, although there were residuals following the first surgery, progress notes following the June 1944 surgery, dated in June and July 1944, indicated that the Veteran's finger was healing well. Overall improvement was again noted. Additionally, in October 1944, the Veteran reported that he had no pain associated with his right hand disability. Moreover, the October 1947 VA examination shortly following service noted that the Veteran had minimal disability following service. The Board places a high probative value on the contemporaneous service treatment records and examination report. The Board acknowledges that a private physician, Dr. B.H., has submitted a letter dated in November 2010 reporting that she had been the Veteran's physician since 2007. In the letter, she expressed her opinion that the surgery done in service caused the current decreased function and disability of the hand. Dr. B.H. did not provide any rationale for her opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion). Nor did she address whether the Veteran's right hand disability demonstrated an increase in disability in service. Moreover, and while not outcome determinative, there is no indication that she reviewed any service treatment records in rendering her opinion, which is important here as those records describe the nature of the Veteran's disability at enlistment, prior to the surgeries, post-surgery, at discharge, and on examination shortly after discharge. Thus, the Board places no probative value on the opinion. Further, the Veteran underwent a VA examination in March 2011. In addition to a physical examination and interview with the Veteran, the March 2011 VA examiner reviewed the November 2010 letter from the private physician. The examiner also noted an August 2001 ambulatory care note in which the Veteran reported right wrist and finger pain for which X-rays were obtained and were consistent with rheumatoid arthritis. The service treatment records as well as records shortly following service were reviewed as well. The rationale for the opinion included the finding that service treatment records did not show evidence of any aggravation or worsening of the right arm/hand condition from the operations performed on the right hand during service. The examiner noted that there was actually documentation of condition improvement. The examiner noted that the operations were considered remedial of preservice disability and it was documented as improved upon completion of surgery on June 1944 and no residuals were noted at discharge. The examiner also found significant that the Veteran had improvement of function to the right hand following surgery in service. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App 171 (1991). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). As noted above, the November 2010 private opinion contained no rationale for the opinion that the right hand disability was service connected. The opinion did not indicate that it was based on a review of service treatment records or that the right hand disability had worsened in severity during service. By contrast, the VA examiner's opinion provided detailed for his negative opinion and cited to evidence in the service treatment records. Thus, the Board affords the record no probative value. The Board also acknowledges that a Report of Physical Examination prior to discharge from active service, dated in April 1946 notes an operation in service on the right arm in November 1943 that was aggravated by service. The examination report contains a form for a list of injuries and corresponding with the injuries listed are a series of boxes for which yes or no answers are contained. Specifically, the boxes in this case included answers of "yes" in boxes labeled "existed prior to service" and "aggravated by military service" and "present physical defects" in relation to the right hand surgery. A box labeled "incurred in military service" contained the answer "no". Notably, the date of the surgery identified was not actually one of the surgery dates for the Veteran but the Board gives the Veteran the full benefit of the doubt and assumes the report is in reference to one of his actual surgeries. Significantly, the report contains no explanation for the answer "yes" to aggravation in service even though the instructions on the form allow for further explanation to be included if necessary. As the form contained no explanation for its conclusion, particularly in light of the remaining service treatment records which indicate improvement of function, the Board places no probative value on the form examination report. In a recent decision, the Court of Appeals for Veteran's Claims addressed the issue of whether an unexplained "x" in a box on a form could constitute clear and unmistakeable evidence of a lack of aggravation. See Horn v. Shinseki, __ Vet.App. __ (June 21, 2012), 2012 WL 2355544 (Vet.App.). Unlike the present case, in Horn, the Veteran's preexisting disability was not noted on entrance. The presumption of soundness was rebutted and the analysis shifted to determining whether the preexisting disability was aggravated by service. There was one piece of evidence pertaining to the issue of aggravation and that was a box on a medical evaluation board form that contained an "x" indicating that the condition was not aggravated by active duty. There was no analysis associated with the "x" on the form. While the issue in the present case is not a form which notes a lack of aggravation without explanation, the principle is the same. In Horn, the Court determined that reliance on the unexplained "x" on the form is untenable. The Court held that in cases regarding presumption of soundness, adjudicators could not deny claims based on medical evaluation board reports containing no supporting analysis. The Court held that such a report could not be considered clear and unmistakeable evidence of a lack of aggravation. While the case at present does not require clear and unmistakeable evidence of an increase in severity of the Veteran's disability, the principle of the Horn case regarding unexplained notations still applies. In determining that VA has the authority to reject a medical evaluation board report if its determination is not explained, the Court has determined that VA is not bound by unexplained findings on service examination reports. Here, the unexplained notation on the service separation examination does not indicate any rationale for finding aggravation by military service. Thus, the Board affords it no probative value. As noted above, the contemporaneous medical evidence of record does not indicate a worsening of the disability but rather improvement at times and at worst, still a minimal disability shortly following service, which the Board finds is the baseline of the disability upon entry to service. The Board acknowledges the Veteran's statement that he entered service with a trigger finger and left service with a claw, but finds the statement not credible. A contemporaneous examination undertaken in October 1947 ultimately found the Veteran had a minimal disability and described in detail the various abilities regarding motion of the fingers. The Board finds that the Veteran's description of a claw is an exaggeration of a memory of the hand from over 60 years prior to the hearing. T. page 9. The Board places greater probative value on the objective examination report dated shortly following service. Based on the foregoing, the Board finds that the Veteran's disability did not increase in severity during service and was at the very least back to the baseline that it was upon entry to service, if not improved. As an increase in severity has not been shown, the presumption of aggravation does not apply. Based on the foregoing, the claim for service connection for loss of grip strength and tendon damage must be denied. b. Arthritis of the Right Hand Also on appeal is the Veteran's claim for service connection for arthritis in the right hand that he contends is due to the surgeries in service. The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment will not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1). In this case, the Board finds that the surgeries in service had an ameliorating effect on the right hand disability or worst case, brought the Veteran to the baseline from whatever worsening he may have felt between the time of his entry to service and surgery in service. Therefore, if the Veteran's current arthritis is a usual effect of the surgery, it will not be considered service connected unless the disease or injury is otherwise aggravated by service. As shown above, the Board has found that the right hand disability did not undergo an increase in severity in service and therefore, was not aggravated by service. Id. To the extent that the Veteran contends his arthritis may be otherwise related to service, the Board will address direct service connection. Notably, service treatment records do not reference any additional trauma to the right hand in service. Post-service treatment records first note rheumatoid arthritis of the right hand in September 2001, over 60 years following separation from service. Service connection is not warranted on a presumptive basis for a right hand arthritis as the evidence does not demonstrate a diagnosis of chronic arthritis in service or within one year following service. Significantly, an October 1947 VA examination did not diagnose arthritis of any kind. The Board acknowledges the Veteran's statements that his right hand contracture symptoms have been continuous since service. However, the Veteran has not indicated that arthritis symptoms have been continuous since service. T. page 7. Specifically, the Veteran offered sworn testimony that as he gets older, "arthritis begins to get into that same hand..." He explained that the combination of the original injury and the arthritis has become too much to handle. Id. He also reported that he had a discussion with his treatment provider about the etiology of the arthritis and that it might be related to service "even though it shows up after so many, many more years ...." In other words, the Veteran is not claiming that he has had arthritis since service. However, to the extent that he may claim that his right hand contracture symptoms are arthritis symptoms that are continuous since service, the Board will analyze whether service connection is warranted for continuity of symptomatology. Post-service treatment records noted osteoporosis and rheumatoid arthritis in September 2001, nearly 60 years following service. The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir.1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. Barr v. Nicholson, 21 Vet.App. 303, 307 (2007). The Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board acknowledges the Veteran's statements and sworn testimony that he has had continuous right hand symptomatology since service. The Board finds the Veteran's testimony that he had continued symptoms of contracture of the right hand competent as this symptom came to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Board finds that he is not competent to diagnose an onset date for arthritis. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Moreover, as noted above, the Veteran has offered sworn testimony that his arthritis began many years following service. Therefore, any assertion that arthritis symptoms have been present since service is not credible and has no probative value. Next, service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. In this case, the Board finds that the weight of the competent evidence weighs against attributing the Veteran's right hand disorder to active duty, despite his contentions to the contrary. The first documented finding of osteoporosis and rheumatoid arthritis was in September 2001. The September 2001 X-ray findings confirmed rheumatoid arthritis in the right hand. A September 2001 X-ray report noted that the right hand study outlines osteoporosis, ulnar deviation of the metacarpal-phalangeal joints and extensive changes between the carpal bones suggesting underlying rheumatoid arthritis. The soft tissues also outline apparent soft tissue swelling in the proximal interphalangeal joint regions. The impression was that the study shows changes suggesting rheumatoid arthritis of the hands and wrists. A December 2007 VA X-ray indicated that the right hand study outlines osteoporosis but no significant post traumatic deformity. The impression was an old trauma to the right wrist with scapholunate disassociation and subsequent degenerative changes. A subsequent VA X-rays undertaken in June 2008 resulted in an impression of osteoarthritis and osteoporosis with probable old scapholunate disassociation and flexion deformities. The Board acknowledges a November 2010 letter from a private physician, Dr. B.H., who reported that she had been the Veteran's physician since 2007 and that the surgery done in service caused the decreased function and disability of the hand. She also opined that the surgery in service likely contributed significantly to the arthritis in the hand. Dr. B.H. did not provide any rationale for her opinions. Thus, the Board places limited probative value on the opinion. Further, Dr. B.H. did not address the type of arthritis present in the Veteran's hand. Specifically, she did not discuss whether the Veteran had rheumatoid arthritis or degenerative arthritis, nor explain how the arthritis is related to the surgery in service. As noted above, even if the arthritis is the usual effect of such surgery in service, it will not be service connected unless it is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1). In contrast, the Board places significant probative value on a March 2011 VA examination undertaken specifically to address the issue on appeal. The March 2011 examiner reviewed all of the evidence of record, including the VA outpatient x-ray reports and the November 2010 private medical opinion. Based on the examiner's review of the evidence, the examiner noted that the evidence suggested radiological evidence of rheumatoid arthritis in the right hand. The examiner opined that the Veteran's in-service surgeries are not associated with rheumatoid arthritis as RA is an autoimmune disease. The Board places a high probative value on the March 2011 VA examination report. The Board acknowledges that the March 2011 VA examiner noted the Veteran's work history and there may have been some misunderstanding regarding the Veteran's role in his construction job, it is not material as the basis of the examiner's opinion of a lack of relationship to in-service surgery is that rheumatoid arthritis is an autoimmune disease and not associated with surgery. The Board acknowledges the Veteran's belief that his right hand arthritis is related to service, but the Board finds the Veteran is not competent to offer an opinion on the etiology of his arthritis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Because causation of rheumatoid arthritis is not diagnosed by unique and readily identifiable features, it does not involve a simple identification that a layperson is competent to make. Therefore, the Veteran's unsubstantiated statements regarding the claimed etiology of his right hand arthritis are afforded little to no probative weight. The Board places a higher probative value on the March 2011 VA examiner's opinion as he expressed adequate rationale and is experienced in determining the etiology of right hand arthritis, including but not limited to, rheumatoid arthritis. Based on the foregoing, Shedden element (3) has not been met. Further, the Board places a high probative value on the medical opinion of record which confirms that the Veteran's arthritis is not related to service. Accordingly, the Board finds that the preponderance of the evidence is against his claims for service connection for loss of grip and tendon damage of the right upper extremity as well as arthritis of the right hand. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against his claim. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for loss of grip and tendon damage of the right upper extremity is denied. Service connection for arthritis of the right hand is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs