Citation Nr: 1303448 Decision Date: 02/01/13 Archive Date: 02/08/13 DOCKET NO. 09-45 214 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for carpal tunnel syndrome (CTS) of the right wrist. 2. Entitlement to service connection for a low back disability to include as secondary to service-connected patellofemoral pain syndrome of the left knee. 3. Entitlement to an increased rating for patellofemoral pain syndrome of the left knee, currently rated as 10 percent disabling. 4. Entitlement to an increased rating for right shoulder tendonitis, status post arthroscopic surgery for impingement syndrome, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARINGS ON APPEAL Veteran ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from July 1993 to July 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In November 2012, the Veteran testified before the undersigned at a Board hearing via video conference from the RO. The issues of service connection for a low back disability to include as secondary to service-connected patellofemoral pain syndrome of the left knee; an increased rating for patellofemoral pain syndrome of the left knee; and an increased rating for right shoulder tendonitis, status post arthroscopic surgery for impingement syndrome, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGSOF FACT CTS of the right wrist is not attributable to service. CONCLUSION OF LAW CTS was not incurred or aggravated in active service. 38 U.S.C.A. §§ 1101, 1110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304. 3.306 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim, including apprising him or her of the information and evidence he or she is responsible for providing versus the information and evidence VA will obtain for him or her. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). This notice must include information that a "downstream" disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, this notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary notice and then readjudicating the claim - including in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has made clear that VCAA notice errors are not presumptively prejudicial, rather, must be determined on a case-by-case basis, and that, as the pleading party attacking the agency's decision, the Veteran, not VA, bears this burden of proof of establishing there is a VCAA notice error and, moreover, above and beyond this, that the error is unduly prejudicial, meaning outcome determinative of the claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of the claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir., 2004). A VCAA letter was sent in February 2007 which indicated the type of evidence and information needed to substantiate the claim and apprised the Veteran of the Veteran's and VA's respective responsibilities in obtaining this supporting evidence. The letters also notified the Veteran that a "downstream" disability rating and an effective date for the award of benefits would be assigned if service connection was granted, in compliance with Dingess. The Veteran has also been afforded hearings before a Veterans Law Judge (VLJ) as well as an RO Decision Review Officer (DRO) in which he presented oral argument in support of his claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims ("the Court") held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ/DRO 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 issue and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ and DRO did not specifically note the bases of the prior determination or the elements that were lacking to substantiate the claim. The VLJ and DRO asked specific questions, however, directed at identifying whether the Veteran had elements necessary to establish the claim of service connection. The VLJ and DRO also sought to identify any pertinent evidence not currently associated with the claim and the Veteran also volunteered his treatment history and symptoms since service. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board/DRO hearing. By contrast, the hearings focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the VLJ/DRO complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Regarding the duty to assist, VA also satisfied this obligation in terms of obtaining all potentially relevant evidence concerning the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records (STRs), VA medical treatment records, and identified private medical records were obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication that any additional evidence, relevant to these claims, is available and not part of the claims file. The Veteran also was provided VA compensation examinations, including for a medical nexus opinion concerning the etiology of the claimed CTS of the right wrist disorder and any potential relationship with military service in April 2009. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The medical nexus opinions obtained is responsive to the determinative issue of causation, so additional examinations and opinions are not needed. 38 C.F.R. § 4.2. See also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). And see Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (VA's duty to assist includes providing an adequate examination when such an examination is indicated). The examinations of record is adequate to address all pertinent concerns, as the Veteran's history was reviewed, the Veteran examined, the findings reported in sufficient detail, and there was discussion of the underlying medical rationale, which is where most of the probative value of an opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The VA examination reports are thorough and supported by the record. The records taken as a whole satisfy 38 C.F.R. § 3.326. At his Board hearing, the Veteran testified that he had been told by medical professionals that his CTS of the right wrist was related to service and he intended to submit medical evidence in support of his claim of service connection for CTS within 30 days. However, no additional evidence was forthcoming from the Veteran as to this issue. In summary, the Board finds that "it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claim." See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances as to when a remand would not result in any significant benefit to the Veteran). Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. Establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current 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); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Other diseases initially diagnosed after service also may be service connected if the evidence, including that pertinent to service, shows the diseases were incurred in service. 38 C.F.R. § 3.303(d). If however chronicity (permanency) of disease or injury in service is not shown, or legitimately questionable, then a showing of continuity of symptomatology following service is required to support the claim. 38 C.F.R. § 3.303(b). See also Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). Under § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Savage v. Gober, 10 Vet. App. 494-97 (1997); 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). To establish a showing of chronic disease in service, or within a presumptive period per 38 C.F.R. § 3.307, a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic," is required. 38 C.F.R. § 3.303(b). Subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Id. In-service notation of a condition does not require medical evidence where "the condition is of a type as to which a lay person's observation is competent." Savage, 10 Vet. App. at 497. However, although prong (3) does not require medical nexus evidence, "because it would not necessarily follow that there is a relationship between any present disability and the continuity of symptomatology demonstrated, medical evidence is required to demonstrate such a relationship unless such a relationship is one as to which a lay person's observation is competent." Id (citations omitted). A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). However, 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, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). Savage, 10 Vet. App. 488, 494-97. When, for example, a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr. Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As held in Davidson, section 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. See also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence" such as actual treatment records). The Veteran is competent to report what he can observe and feel through the senses. See Layno. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). "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 the evidence also is credible, as only then does it ultimately have probative value. See Layno (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")); Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). In rendering a decision on appeal, 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 or bases for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). To this end, the Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court), citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court similarly has declared that, in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing when he/she has testified. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, aff'd per curiam, 78 F.3d 604(Fed. Cir. 1996). See, too, Macarubbo v. Gober, 10 Vet. App. 388 (1997) (similarly holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record, medical and lay, and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. In hearing testimony and in written correspondence, the Veteran asserted that he began having problems with CTS of the right wrist in 2003 and was told by his doctor that the CTS was due to performing repetitive motions. He said that he believed that his doctor thought that the work that he performed in the service involving repetitive lifting and loading ordnance into aircrafts might have had something to do with his CTS. The Veteran stated that he did not report any wrist problems at separation and also indicated that he did not have symptoms such as swelling of the hands/fingers/wrist or numbness/tingling during service. The Veteran indicated that post-service, he worked in the mechanics field and continued using repetitive motions. At the present time, he used repetitive motions in utilizing a keyboard. Competent lay evidence may establish the presence of observable symptomatology and, in certain circumstances, it may provide a basis for establishing service connection. See Barr. Although claimants may be competent to provide the diagnoses of simple conditions, such as a broken leg, they are not competent to provide evidence on more complex medical questions beyond simple observations. Jandreau; see Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). Indeed, even if lay testimony is competent, should VA find it to be mistaken or lacking credibility, the Board may reject it as unpersuasive and, thus, not ultimately probative. Buchanan; see also Rucker and Layno. The Board may find a lack of credibility in, for example, conflicting medical statements or witness biases. Buchanan at 1337. The lack of contemporaneous medical evidence is also relevant; however, the mere lack of such evidence may not constitute the sole basis for discrediting the lay evidence. Id. This case involves a complex question regarding the etiology of the Veteran's CTS of the right wrist. As such, and as set forth below, a medical opinion has been obtained. The STRS reflect that the Veteran slammed his right forearm/wrist in a metal door in December 1994. Physical examination revealed slight swelling of the right wrist with discoloration and a small abrasion. There was no bruising and range of motion was full. Pain was noted. The diagnosis was contusion of the right forearm. X-rays revealed no fracture. There was no mention of any neurological abnormality nor was CTS of the right wrist diagnosed. On his separation examination in January 1999, the Veteran did not report any complaints relating to his right wrist. His physical examination of the upper extremities was normal. His neurological evaluation also yielded normal findings. Post service, private medical records dated in June 2006 noted that the Veteran had a history of getting his hand caught in a door during service. However, physical examination revealed full range of motion of the wrists, fingers, and hands, bilaterally. There was tenderness over a small cyst/mass in the dorsum of the wrist on the right which was more pronounced on dorsiflexion. In addition, the Veteran reported occasional tingling in the ulnar distribution on the right side. Aspiration of the right wrist was recommended. Further evaluation of the right wrist revealed a ganglion cyst. In November 2006, the Veteran was afforded a VA examination. At that time, the Veteran reported that he would get right wrist pain with prolonged writing and experienced lesser grip strength. He also reported having numbness and indicated that he had undergone steroid injections in the past. Physical examination was performed. X-rays were negative. The examiner indicated that the Veteran had positional CTS where he would sleep with his wrist in a flexed position which caused his whole hand to be numb the next morning. If he used a wrist sprint and kept it in an extended position, he did not have these symptoms. The examiner opined that this was not related to any kind of injury at all and certainly not related to an injury during the military. In essence, the examiner indicated that the positional CTS was due to the way that the Veteran slept with his wrist in a certain position. In April 2009, the Veteran was afforded another VA examination. At that time, the inservice injury was reviewed. The Veteran reported that his numbness and tingling of the right wrist commenced in 2003. He was subsequently treated for a ganglion cyst. A physical examination was performed and x-rays were taken. The x-rays were negative. The examiner confirmed the diagnosis of right wrist CTS, but opined that it was not related to or aggravated by treatment in service for a right wrist condition and was less likely than not due to service. The examiner stated that the Veteran's right wrist CTS as well as his ganglion cyst did not have their onset during service and were most likely due to his current occupation as an aircraft mechanic. The STRs do not reflect any neurological abnormality or diagnosis relative to the right wrist. In cases involving combat, VA is prohibited from drawing an inference from silence in the STRs. But in cases where this inference is not prohibited [i.e., non-combat scenarios], the Board may use silence in the STRs as contradictory evidence if the alleged injury, disease, or related symptoms ordinarily would have been recorded in the STRs. Kahana; see also Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (For non-combat Veterans providing non-medical related lay testimony regarding an event during service, Buchanan is distinguishable; the lack of documentation in service records must be weighed against the Veteran's statements.). In this circumstance, the Board must make two preliminary findings in order to rely on this inference (see Kahana): (a) First, the Board must find that the STRs appear to be complete, at least in relevant part. If the SMRs are not complete in relevant part, then silence in the STRs is merely the absence of evidence and not substantive negative evidence. See also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (cautioning that negative evidence, meaning actual evidence weighing against a party, must not be equated with the absence of substantive evidence). (b) If the STRs are complete in relevant part, then the Board must find that injury, disease, or related symptoms ordinarily would have been recorded had they occurred. In making this determination, the Board may be required to consider the limits of its own competence on medical issues. Ultimately, the Board must consider all the evidence relevant to the claim, including the availability of medical records, the nature and course of the disease or disability, the amount of time that has elapsed since military service, and any other pertinent facts. Cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact-finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). In this case, that the STRs appear to be complete. In addition, the STRs document numerous complaints, findings, treatment, and diagnoses of other medical issues, including for a contusion of the right wrist. As such, the Board finds that had the Veteran shown manifestations of neurological injury or disease during service, they would have been recorded had they occurred. The Veteran in fact states that his symptoms and diagnosis began after service. He asserts that he has been told by his doctor that his CTS is etiologically related to inservice motor movements on his right wrist/hand/fingers. However, although he stated that he would submit evidence to this effect, he did not do so. In contrast, two VA examiners opined that the Veteran's CTS is not etiologically related to service. The VA examiners respectively felt that the CTS of the right wrist was due to a positional problem when the Veteran slept as well as due to his current job duties. In any event, both opined that the current diagnosis was not related to service. The Board recognizes that the two VA examiner's had different opinions regarding the etiology. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez. The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ( "[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In this case, both examiners were aware of the Veteran's medical history, provided an articulated opinion, and also furnished a reasoned analysis. However, although a review of the claims file is not necessary, the second examiner provided additional discussion regarding the inservice injury. As such, the Board therefore attaches more probative value to this opinion, and the most probative value in this case, as it is well reasoned, detailed, consistent with other evidence of record, and included an access to the accurate background of the Veteran. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Veteran has not provided any countervailing medical opinion, although he stated that he intended to do so. The record is devoid of any medical opinion attributing CTS of the right wrist to service. Although the Veteran has competently reported his symptoms, he indicated that the onset of his CTS symptoms began post service. Due to the history of any inservice injury and the report of symptoms of CTS which were first dated after service, the case involves medical complexities more adequately addressed by a medical professional. The most probative opinion, as noted above, does not attribute the Veteran's CTS of the right wrist to service and is simply more probative than the Veteran's personal opinion in this case, due to the complicated nature of the medical history. Therefore, the evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The preponderance is against the Veteran's claim, and it must be denied. ORDER Service connection for CTS of the right wrist is denied. REMAND Unfortunately, a remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that the Veteran is afforded every possible consideration. The Veteran claims that he has a low back disability which is either directly related to service or which is aggravated by his service-connected left knee disability. He has testified that his duties during service involved heavy lifting which resulted in a low back disability, as he purports he has been told by numerous physicians. Further, he also asserted that his physicians have told him that his left knee disability caused an altered gait and limp, but he was required to run on it, and all of this action aggravated his low back disability. In addition, he maintained that the assessment by the VA examiner in August 2009 that he basically does not have an actual back disability is inaccurate as he has submitted medical records establishing that he does have a low back disability. A review of the August 2009 examination shows that the VA examiner essentially determined that the Veteran had a normal lumbosacral spine. The examiner noted that a magnetic resonance imaging (MRI) revealed a bulging disc, but noted that bulging discs were not pathologic and were not symptomatic unless they have a broad bulge that can actually impinge on a neural element, which the Veteran did not have. The examiner stated that the Veteran had more of a somatization issue than a physical problem. The examiner opined that there was not an etiological connection to the service-connected left knee disability. A separate opinion regarding direct service connection was not provided. Thereafter, additional evidence was received from the Veteran which included diagnoses of lumbar radiculitis with herniated nucleus pulposus, disorder of the intervertebral disc, post-laminectomy syndrome, and spinal stenosis. Based on the additional medical evidence as well as the lay statements, the Board is satisfied that there is a currently diagnosed low back disorder. Since the clinical findings on the last VA examination were not consistent in that regard, the Veteran should be afforded a new examination, rather than an addendum, to include a medical opinion regarding whether any current diagnosis is etiologically related to service or to his left knee disability. With regard to the increased rating claims for the left knee and the right shoulder, at his Board hearing, the Veteran testified that both disabilities have worsened, particularly as related to increased pain. A review of the most recent 2009 VA examination does not show that pain caused limitation of either the left knee motion where no pain was noted, or the right shoulder where pain was noted, but no additional limitation indicated. Accordingly, the Veteran should be afforded a new VA joints examination to assess the current level of disability of both the left knee and the right shoulder. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be notified that if he wishes to submit further medical opinions in support of his claim for service connection for a low back disability, he may do so. 2. Schedule the Veteran for a VA spine examination. The claims file must be made available to the examiner and the examiner should indicate in his/her report whether or not the record was reviewed. Any indicated tests, including X-rays if indicated, should be accomplished. Based on a review of the claims file and any examination findings, the examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current low back disability, including, but not limited to lumbar radiculitis with herniated nucleus pulposus, disorder of the intervertebral disc, post-laminectomy syndrome, and spinal stenosis, is proximately due to, or the result of, the service-connected left knee disability. The examiner should also provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current low back disability is permanently aggravated (worsened) by the Veteran's service-connected left knee disability. If such aggravation is found present, the examiner should address the following medical issues: (1) The baseline manifestations of the Veteran's low back disability found present prior to aggravation; (2) The increased manifestations which, in the examiner's opinion, are proximately due to the service-connected left knee disability based on medical considerations. Finally, the examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current low back disability is otherwise related to the Veteran's military service. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 3. Schedule the Veteran for a VA joints examination for the purpose of determining the nature and extent of the Veteran's service-connected left knee disability and service-connected right shoulder disability. The record must be made available to the examiner and the examiner should indicate in his/her report whether or not the record was reviewed. Any indicated tests, including x-rays if indicated, should be accomplished. With regard to the left knee: The examiner should perform range of motion and state the Veteran's range on flexion and extension and if he has pain on either movement. The examiner should indicate if the Veteran has recurrent subluxation or instability and, if so, if it is slight, moderate or severe. The examiner should also, in accordance with DeLuca v. Brown, 8 Vet. App. 202 (1995), indicate whether the service-connected left knee disability is productive of any weakened movement, including weakened movement against varying resistance, excess fatigability with use, incoordination, painful motion, pain with use, and provide an opinion as to how these factors result in any additional limitation of motion or additional functional loss. If the Veteran describes flare-ups of pain, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups, and if feasible, express this in terms of additional degrees of limitation of motion during the flare-ups. If the examiner is unable to offer an opinion as to the nature and extent of any additional disability during a flare-up, that fact must be so stated. The examiner should indicate if the Veteran had a dislocated semilunar cartilage, and, if so, if he also has frequent episodes of locking, pain, and effusion in the joint. The examiner should indicate if the Veteran has ankylosis of the knee. With regard to the right shoulder: The examiner should perform range of motion and state the Veteran's range on forward elevation and abduction and if he has pain on either movement. The examiner should also, in accordance with DeLuca indicate whether the service-connected right shoulder disability is productive of any weakened movement, including weakened movement against varying resistance, excess fatigability with use, incoordination, painful motion, pain with use, and provide an opinion as to how these factors result in any additional limitation of motion or additional functional loss. If the Veteran describes flare-ups of pain, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups, and if feasible, express this in terms of additional degrees of limitation of motion during the flare-ups. If the examiner is unable to offer an opinion as to the nature and extent of any additional disability during a flare-up, that fact must be so stated. The examiner should also state if the Veteran has impairment of the humerus and if there is malunion, with moderate deformity; or marked deformity. The examiner should indicate if the Veteran has recurrent dislocations of the scapulohumeral joint, and, if so, if there have been infrequent episodes, and guarding of movement only at shoulder level; or frequent episodes and guarding of all arm movements. The examiner should state if the Veteran has fibrous union; nonunion (false flail joint); or loss of head of (flail shoulder) for his major (right) arm. The examiner should indicate if the Veteran has impairment of the clavicle or scapula with malunion or nonunion without loose movement; or has nonunion with loose movement; or has malunion. The complete examination findings, along with the complete rationale for all opinions expressed, should be clearly set forth in the examination report. 4. The AMC should review the medical opinion and examinations obtained above to ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, AMC should return the case to the examiner for completion of the inquiry. 5. The AMC should then readjudicate the claims on appeal in light of all of the evidence of record. If any issue remains denied, the Veteran should be provided with a supplemental statement of the case as to any issue remaining on appeal, and afforded a reasonable period of time within which to respond thereto. 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 2002 & Supp. 2012). ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs