Citation Nr: 1304219 Decision Date: 02/06/13 Archive Date: 02/19/13 DOCKET NO. 07-24 096A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to compensation under 38 U.S.C.A. § 1151 for a right shoulder and arm injury. 2. Entitlement to compensation under 38 U.S.C.A. § 1151 for an ankle injury. 3. Entitlement to compensation under 38 U.S.C.A. § 1151 for a back injury. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Mac, Counsel INTRODUCTION The Veteran served on active duty from September 1972 to June 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, which denied the benefits sought on appeal. The Veteran appealed that decision to the Board, and the case was referred to the Board for appellate review. A hearing was held on July 30, 2009, by means of video conferencing equipment with the appellant in Chicago, Illinois, before the undersigned Veterans Law Judge sitting in Washington, DC, who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107(c), (e)(2) and who is rendering the determination in this case. A transcript of the hearing testimony is in the claims file. The Board issued a decision that denied the benefits sought on appeal in September 2009. The normal procedure in cases where a Veteran has a Board hearing is that the hearing transcript is usually the last item of evidence added to the record, unless there is a remand, before the Board decides the case. However, as the result of a settlement in litigation between the Veteran's representative and the Secretary in 1997, the Veteran's representative is entitled to submit additional argument/evidence in the case following any Board hearing. As the Veteran's representative was not afforded such an opportunity in 2009, the Board in April 2010 vacated its decision dated in September 2009. Subsequently, the Veteran's representative submitted briefs dated in March 2010 and in August 2012. In April 2010, the Board also remanded the issues for further development. As the requested development has been completed, no further action to ensure compliance with the remand directive is required. Stegall v. West, 11 Vet. App. 268 (1998). A review of the Virtual VA paperless claims processing system shows additional documents which are either duplicative of the evidence of record or are not pertinent to the present appeal. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. The Veteran has not been shown to have any additional right shoulder and arm disability as a result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA health care providers who provided physical therapy in May 2005, nor does the evidence show that any additional disability was due to an event that was not reasonably foreseeable. 3. The Veteran has not been shown to have any additional ankle disability as a result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA health care providers who provided physical therapy in May 2005, nor does the evidence show that any additional disability was due to an event that was not reasonably foreseeable. 4. The Veteran has not been shown to have any additional back disability as a result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA health care providers who provided physical therapy in May 2005, nor does the evidence show that any additional disability was due to an event that was not reasonably foreseeable. CONCLUSIONS OF LAW 1. The criteria for compensation under 38 U.S.C.A. § 1151 for a right shoulder and arm injury have not been met. 38 U.S.C.A. § 1151 (West 2002 Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.361, 17.32 (2012). 2. The criteria for compensation under 38 U.S.C.A. § 1151 for an ankle injury have not been met. 38 U.S.C.A. § 1151 (West 2002 Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.361, 17.32 (2012). 3. The criteria for compensation under 38 U.S.C.A. § 1151 for a back injury have not been met. 38 U.S.C.A. § 1151 (West 2002 Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.361, 17.32 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. The VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided a pre-adjudication VCAA notice by letter dated in November 2005. The Veteran was notified of the evidence needed to substantiate the claims of entitlement to compensation under 38 U.S.C.A. § 1151, as well as what information and evidence must be submitted by the Veteran and what information and evidence would be obtained by VA. The Board does acknowledge that the Veteran but he was not provided with notice of the type of evidence necessary to establish a disability rating or effective date. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). However, the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the veteran has been prejudiced thereby). The Board concludes below that the Veteran is not entitled to compensation pursuant to 38 U.S.C.A. § 1151. Thus, any questions as to the disability rating or appropriate effective date to be assigned are rendered moot. In addition, VA has fulfilled its duty to assist in obtaining all identified and available evidence needed to substantiate the claims. All identified and available VA medical records are in the claims file and were reviewed by both the RO and the Board in connection with the claims. The Board does note that the claims file does not contain a copy of the Veteran's service treatment records. However, as the issues before the Board concern entitlement to compensation under 38 U.S.C.A. § 1151 regarding an incident that occurred at a VA medical facility in May 2005, as opposed to an incident that occurred many decades earlier on active duty between September 1972 to June 1974, the Board finds that the Veteran's service treatment records are irrelevant for the purposes of these claims. The Veteran was also provided the opportunity to testify at hearing before the Board, and he was afforded a VA examinations in April 2007 in connection with his claims in accordance with 38 C.F.R. § 3.159(c)(4). Additional medical opinions were provided by the same examiner in November 2008, in July 2010, and in August 2011. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In the remand in April 2010, the Board requested that written confirmation to be obtained as to whether formal consent is a general practice for physical therapy and for the examiner, Dr. R.N., who conducted the April 2007 VA examination, to provide an opinion as to whether the Veteran's ulnar neuropraxia was present after September 22, 2005. In a brief in August 2012, the Veteran's representative questioned whether there was compliance with Board's remand directives. The Board finds that its remand directives were fully complied with, as Dr. R.N. stated in July 2010 that the Veteran's ulnar nerve neuropraxia resolved by August 2005, which was prior to the receipt of his claims for compensation under 38 U.S.C.A. § 1151 in September 2005 and explained that written consent was not required for physical therapy. The Board finds that the VA examinations and medical opinions obtained in this case are more than adequate, as they are predicated on a full reading of the claims file and available treatment records as well as on physical examinations. The medical opinions are thorough and rationale. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Veteran has not made the Board aware of the any additional, relevant evidence that has not already been obtained and associated with the claims file. VA has further assisted the Veteran throughout the course of this appeal by providing him with a statement of the case and supplemental statements of the case, which informed him of the laws and regulations relevant to his claims. For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Legal Criteria The Veteran filed his claims for compensation under the provisions of 38 U.S.C.A § 1151 in September 2005. 38 U.S.C.A. § 1151 provides that compensation shall be awarded for a qualifying additional disability or a qualifying death of a Veteran in the same manner as if such additional disability or death were service-connected. 38 U.S.C.A. § 1151. A disability or death is a qualifying additional disability or qualifying death if the disability or death was not the result of the Veteran's willful misconduct and (1) the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by the Secretary, either by a VA (Department) employee or in a Department facility as defined in 38 U.S.C.A. § 1701(3)(A), and (2) the proximate cause of the disability or death was (a) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or (b) an event not reasonably foreseeable. Id. The implementing regulation applicable to 1151 claims received on or after October 1, 1997 is 38 C.F.R. § 3.361, which provides that, in order to determine whether a Veteran has an additional disability, VA compares the Veteran's condition immediately before the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy program upon which the claim is based to the Veteran's condition after such care, treatment, examination, services, or program has stopped. VA considers each involved body part or system separately. 38 C.F.R. § 3.361(b) Under 38 C.F.R. § 3.361(c), a claim based on additional disability due to VA medical treatment requires actual causation. To establish causation, the evidence must show that the VA surgical treatment resulted in the veteran's additional disability. Under 38 C.F.R. § 3.361(d), to establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing medical treatment, it must be shown that the surgical treatment caused the additional disability; and VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or that VA furnished treatment without the informed consent of the veteran and his representative in compliance with 38 C.F.R. § 17.32. Consent may be express or implied as specified under 38 C.F.R. § 17.32(b), as in emergency situations. 38 C.F.R. § 3.361(d)(1). Informed consent must be documented appropriately in the record. Signature consent is required for the use of sedation, anesthesia or narcotics; situations causing significant discomfort, risk of complication or morbidity or requiring injections of any substance into a joint space or body cavity. 38 C.F.R. § 17.32(d). Whether the proximate cause of an additional disability was an event not reasonably foreseeable is to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). Evidence Contentions and Lay Evidence The Veteran, through his representative, submitted an informal claim for benefits that was received on September 22, 2005. The claim did not provide any specifics as to the disabilities claimed, only that the Veteran was seeking benefits under 38 U.S.C.A. § 1151 as a result of a fall while receiving treatment at a VA facility. The Veteran's representative submitted a statement to define the specific disabilities involved in December 2005. These included the right arm and shoulder, lower back, and ankle. The Veteran contends that he injured himself by falling during a physical therapy session on May 10, 2005, at a VA medical facility. In particular, he asserted at the July 2009 Board hearing that a physical therapist demonstrated an exercise for him to perform, which involved standing between parallel bars on a board with a ball underneath. The Veteran claimed that the physical therapist did not put a safety belt on him, instructed him to perform the exercise, and left the room. He stated that he fell to the side while attempting to perform the exercise and that his arm caught on one of the parallel bars. He testified that, when he used the parallel bars in the past, a safety belt was used. As a result, the Veteran indicated that he injured his right arm and shoulder, ankle, and back. Medical Evidence VA Progress Notes The claims folder is replete with extensive VA progress notes dated from 1999 to 2011. The records show the Veteran had suffered a number of injuries as a result of being struck by an automobile in January 1995, to include a fractured left ankle. He had surgery to remove plates from his left ankle in May 2000. He also suffered a left knee injury following a personal assault in January 2001. In January 2001, he was beaten and hurt his arms; however, he did not incur additional injuries and a x-ray report in February 2001 shows an old fracture of the medial epicondyle with degenerative changes. In May 2001, VA records show that the Veteran reported that he also fractured his right ankle during the motor vehicle accident in January 1995. In November 2001, he complained of upper back pain radiating down his right arm with numbness. VA records show that in March 2002, the Veteran had a pedestrian motor vehicle accident, whereby he was hit by vehicle traveling at low speeds and sustained a right tibial fracture, a right subarachnoid hemorrhage, and skull fractures. He was hospitalized by VA and the discharge diagnoses in April 2002 also include mobility impairment, cognitive impairment, and a traumatic brain injury. The Veteran has been receiving extensive therapy for the injuries he incurred during this accident. In May 2003, imaging studies also show extreme osteoporosis in the right shoulder. There is a problem list associated with an outpatient entry from May 4, 2005. The list reflected a number of serious diagnoses/problems, which included a head injury in March 2002; a closed fracture of the base of the skull with cerebral laceration and contusion in March 2002; open treatment of a tibial fracture of the proximal plateau in March 2002; organic affective syndrome in August 2002; spastic hemiplegia and hemiparesis of the dominant side in March 2004; acute, but ill-defined, cerebrovascular disease in May 2004; neck pain in September 2004; low back pain in January 2005; a fracture of the tarsal/metatarsal in January 2005; and, a fracture of the ankle, in April 2005. An entry in May 4, 2005, indicated that the Veteran had been involved in a prior motor vehicle accident. He was being seen for complaints of pain in his right shoulder, right neck, and right leg. The pain had been present for two years. He received a cervical steroid injection for treatment of his pain. The Veteran was also seen in physical therapy on May 4, 2005, for treatment relating to a fracture of the right ankle. It was noted that his initial visit was on April 11, 2005. The Veteran was seen again in the physical therapy clinic on May 10, 2005. The clinical entry reflects that the Veteran twisted his left ankle while performing balance activities. He complained of pain of 8-9/10 in the right shoulder and left ankle. It was also noted that the pain subsided somewhat before he left the clinic. The entry further provides that the Veteran was instructed in and performed dynamic standing balance on a BAP board in parallel bars. He slipped off the board at the end of his session and twisted his left ankle and right shoulder without falling to the ground. He was helped back to his wheelchair in pain. It was also noted that the Veteran was examined by a physician and was instructed to seek treatment in the emergency room (ER) should his symptoms worsen. The entry concluded that an incident report was to follow. The incident report for May 10, 2005, shows the Veteran was in the physical therapy clinic performing balance exercises on a balance board on his right lower extremity when he twisted his left ankle and slipped off the BAPS board. He was able to hang on to the parallel bars with his left arm. A physical therapist was present and assisted the Veteran back to an upright position. The Veteran did not fall, but he complained of pain in the right shoulder and left ankle. Dr. C. evaluated the Veteran, and he was cleared of any immediate injury. The Veteran received ice packs to the left ankle and right shoulder for 10 minutes. The left ankle was then ace wrapped. The Veteran was instructed to call the ER should the symptoms worsen. The Veteran was later seen in the ER on May 13, 2005. He complained of pain just above his right elbow. He also complained that there was an increase in his claw hand with extension of his fingers. The initial assessment was right upper extremity elbow strain and ulnar entrapment, and there was diminished range of motion in the right shoulder and normal passive range of motion. An ER nurse recorded the Veteran's complaint as involving pain in the right arm, hip, and leg. However, there were no findings of any lower extremity problems on examination and no mention of any type of back problem by the Veteran. In a June 8, 2005, VA treatment record, it was noted that the Veteran's right upper extremity was spastic and nonfunctional. The physician opined that such symptomatology was not due to an injury sustained at the physical therapy clinic. In this regard, the physician indicated that he had seen the Veteran in the clinic on May 10, 2005. He also commented that the Veteran was at risk for falls and was noncompliant with recommendations. In a July 21, 2005, VA treatment record, the Veteran complained of an injury to the right arm that he sustained in physical therapy on May 10, 2005. A neurology consultation that same date shows that the Veteran had a history of motor vehicle accidents, systemic arterial hypertension, and resultant coma for three weeks with a brain injury. The assessment was ulnar nerve versus plexus injury of the right upper extremity with hyperextension of the right arm at the shoulder level and a history of right hemiparesis with increased tone. The claims file also contains documentation of a fall that occurred on July 31, 2005. A VA treatment record on that date indicated that an ambulance had transported the Veteran from his home due to a fall in the bathroom. It was noted that the Veteran had injured his right ankle and likely sustained a sprain. A neurological evaluation in January 2008 shows that the Veteran had right spastic hemiparesis, with contractures in the elbow, wrist, and fingers secondary to the motor vehicle accident and brain injury. Other VA progress notes show ongoing treatment for the Veteran's multiple disabilities and are cumulative of the evidence already discussed and the information presented in VA examinations and opinions, which will be discussed below. April 2007 VA examination (Dr. R.N.) In April 2007, the Veteran underwent a VA examination. The examiner, Dr. R.N., who is an orthopedic consultant, noted that the Veteran reported having sustained a right brachial plexus injury due to hyperextension of the right arm and shoulder as well as having right ankle pain, which was likely a sprain, due to a fall during a May 10, 2005, physical therapy session. The examiner reviewed the Veteran's relevant medical records in detail, including the May 10, 2005, VA treatment record and noted that the report documented an injury to the right shoulder and left ankle, but not the right ankle. Additionally, the examiner observed that the report indicated that the Veteran was able to hang onto parallel bars with his left arm. He also noted that it was apparent from an emergency department evaluation that the Veteran sustained a contusion to the right arm. The examiner further indicated that the Veteran was involved in a pedestrian motor vehicle accident in 2002 during which he sustained multiple trauma including a right tibial plateau fracture. It is also likely that he sustained a brachial plexus injury. The Veteran initially was hemiplegic on the right, but over time, improved and remained hemiparetic. The examiner referenced a podiatry note in December 2004, which documented right ankle pain after the Veteran had his right foot caught under his wheelchair. X-rays of the ankle showed a fracture fragment. He also noted that a VA progress note in February 2005, documented the Veteran's complaints of right shoulder pain. The examiner found it noteworthy that, when the Veteran went to ER on May 13, 2005, after his physical therapy injury, he did not complain of any ankle pain or right shoulder pain. The examiner stated that the Veteran was brought to the ER again in July 2005 after falling and likely straining his right ankle. He indicated that x-rays of the right ankle in July 2005, August 2005, and October 2005 essentially showed a fracture of the lateral malleolus, which was nondisplaced and essentially healed. The doctor noted that records in October 2005 show that the right ankle pain was resolving. Dr. R.N. cited a VA neurology consultation in December 2005, which indicated that, after the Veteran's injury in physical therapy in May 2005, he developed a marked increase in tone in the right upper extremity, and since that time, the pain decreased somewhat and tone improved somewhat, but still persists. The examination showed weakness of intrinsic hand muscles on the right with increased tone with elbow flexion. There were also increased biceps/brachial radialis tone, increased tone in wrist flexors, and the fingers were flexed at the carpometacarpal joint and extended at the first interphalangeal joints, especially the third and fourth digit. The accompanying nerve conduction velocity (NCV)/electromyograph (EMG) report suggested findings consistent with a lower brachial plexus injury involving the lower trunk and the report indicated that the diffusely decreased recruitment was most likely due to a prior central injury. The April 2007 VA examiner was of the opinion that the other examiner was describing a claw hand, while the Veteran was describing a completely different injury. Dr. R.N. also cited a MRI of the right foot in February 2006, which showed an old evulsion fracture tip of the medial malleolus and non displaced fracture of lateral malleolus. The examiner commented that the MRI in February 2006, when compared to the x-rays in July 2005, shows a different fracture and would represent a different and additional injury. He also cited an EMG/NCV in April 2006, which showed findings that would be consistent with neurogenic injury affecting the right medial plantar nerve. He noted a consultation in February 2007, where the assessment was chronic neck pain and low back pain with right radiculopathy. A MRI in March 2007 of the lumbar spine showed severe disc space narrowing at L5/S1 and signal changes in the endplates compatible with degenerative disc disease. At L4/L5 there was mild disc bulge and facet joint degenerative joint disease with mild bilateral foraminal stenosis. At L5/S1 there was disc bulge and midline herniation. There was moderate central stenosis and mild right foraminal stenosis. As for the Veteran's status at the time of the examination, the examiner stated that the Veteran had deformity of his right hand, right upper extremity pain, and right ankle pain. The examiner noted that the Veteran sustained a subarachnoid hemorrhage from a pedestrian motor vehicle accident in 2002. He was in a coma for three weeks, and he had a right hemiplegia. Motor paralysis improved, and at the time of the examination he was a right hemiparetic. The Veteran had daily pain in his right upper extremity, which was contracted in a pattern typical of a hemiparetic. He complained of daily right ankle pain, and on examination, there was decreased sensation. The examiner commented that the sensory examination was inconsistent and non-reproducible both in the upper and lower extremities. The sensory findings were not anatomically consistent, which may well reflect the underlying brain injury which could cause difficulty in interpreting sensation. Accompanying x-rays of the right shoulder show mild to moderate degenerative changes of the glenohumeral joint and acromioclavicular joint. There was marked osteopenia. X-rays of the right hand show claw deformity of all fingers and boutonniere posturing of the thumb. There was diffuse carpal arthritis and marked osteopenia. As for x-rays of the right ankle, the examiner stated that the lateral malleolar fracture could no longer be identified. There were medial changes consistent with an old avulsion/soft tissue calcification. There were mild degenerative changes and diffuse osteopenia. Upon an extensive and detailed review of the relevant medical records and physical examination, the April 2007 VA examiner diagnosed the Veteran with the following disorders: right hemiparesis; foraminal/central stenosis of the cervical spine at multiple levels with right radiculopathy; brachial plexus injury (post ganglionic root injury to C8/T1); multiple contractures of the right upper extremity with a complex contracture of the right hand; residuals of a right ankle injury with old avulsion fracture/calcification medially; ununited lateral malleolar fracture right ankle by MRI; entrapment of the right medial plantar nerve by EMG/NCV; multi-level disc herniation, foraminal stenosis, and central stenosis of the lumbar spine with right radiculopathy; and, degenerative arthritis of the right shoulder, right carpus, and right ankle. The examiner commented that there was no evidence of an isolated ulnar nerve lesion or a chronic shoulder strain. He stated that the previous shoulder pain could be easily explained by cervical spine pathology, which he noted was a hereditary/aging process that was possibly compounded by the 2002 accident. He noted that the Veteran was treated for right shoulder pain and right upper extremity radiculopathy prior to the incident in May 2005 and that this was a condition that preexisted physical therapy. The examiner was of the opinion that the deformity of the right hand and EMG/NCV study were consistent with an injury to the brachial plexus. The examiner further found that the Veteran had an adduction/internal rotation contracture of the shoulder secondary to the hemiparesis. He concluded that it was impossible for the Veteran to have sustained a hyperabduction injury to his shoulder at the time of the physical therapy incident during when he was supported by the parallel bars and that he would have been able to sustain this type of injury during his 2002 motor vehicle accident, as the force generated by a moving 4000 pound car is consistent with high energy trauma. The examiner concluded that the injury sustained in physical therapy was both insufficient in magnitude and direction to cause an injury to the lower brachial plexus, while the pedestrian/vehicle injury would have been sufficient to cause the lower brachial plexus injury. As for the right hand claw deformity, the examiner found that it is entirely consistent with the brachial plexus root injury. The examiner stated that deformity of the upper extremity due to hemiparesis includes adduction/internal rotation contracture of the shoulder, flexion contracture of the elbow, pronation contracture of the forearm, wrist flexion contracture, flexion contracture of the fingers, and thumb deformity. As for the right ankle, the examiner noted that the Veteran sustained a right ankle injury in December 2004. He indicated that x-rays are consistent with an injury to the medial aspect of the ankle of undetermined age. He noted that the Veteran sustained an additional injury to the right ankle in July 2005, which involved a nondisplaced lateral malleolar fracture. X-rays showed this fracture healed completely. He indicated that the lateral aspect of the ankle is essentially asymptomatic. Dr. R.N. further stated that the injury sustained during physical therapy was to the left ankle. As for the entrapment of the right medial plantar nerve, the examiner stated that it is likely unrelated to the ankle injuries as an ankle fracture/sprain may cause pain, which is manifested by involvement of the branches of the tibial nerve, and the medial and lateral plantar nerves would not likely be confined to involvement of the medial plantar nerve alone. In any event, the examiner determined that this could not be related to the injury sustained in physical therapy and that it is highly unlikely that it was caused by the ankle injury in July 2005. As for the lumbar spine stenosis, the Veteran had chronic low back pain with right radiculopathy, which was consistent with the MRI findings in March 2007. The examiner noted that the radiculopathy may significantly explain right ankle foot pain and numbness. The examiner was of the opinion that this condition was related to the hereditary and normal aging process of the spine and cannot be attributed to the injury sustained during physical therapy. As for degenerative arthritis of the right shoulder, wrist, and ankle, the examiner was of the opinion that these conditions were consistent with an age-related degenerative process and morbidity associated with the hemiparesis. In summary, the April 2007 VA examiner noted that the Veteran sustained an injury to his right arm and left ankle during a physical therapy session on May 10, 2005. He stated that it is well recognized that patients undergoing physical therapy may sustain an injury related to their therapy. He noted that for safety precautions the therapy was performed with the protection of parallel bars and that the physical therapy session was well supervised. Following the incident, the Veteran was evaluated by a physician, and an appropriate incident report was completed. Dr. R.N. commented that, by the very nature of physical therapy, stresses are often applied to extremities, and it is well recognized that injuries, such as strains and sprains occur no matter how carefully the rehabilitation program is structured, implemented, and supervised. Based on the emergency department evaluation on May 13, 2005, and the neurology consultation on July 21, 2005, his conclusion was that there was a contusion to the arm just proximal to the elbow and possibly an ulnar neuropathy. He stated that the EMG/NCV in December 2005 were consistent with a brachial plexus injury and not an ulnar nerve pathology, noting that there was enough time in six months for the transient ulnar neuropathy to resolve. Dr. R.N. also commented that, from the location of the arm contusion as described in the ER notation (posterior medial elbow), the following could be postulated. There was stress applied to the shoulder causing a shoulder strain, which is a self-limited condition, and its natural history would include complete resolution of the shoulder pain. The location of the bruising would be consistent with a contusion of the ulnar nerve at the elbow resulting from a neuropraxic injury, which is transient in nature and natural history suggests complete recovery. The examiner reiterated that the EMG/NCV in December 2005 revealed no residual pathology confined to the ulnar nerve. The examiner stated that it is reasonable that the injuries sustained from the physical therapy incident of May 10, 2005, involved the following: contusion of the right arm, strain of the right shoulder, ulnar nerve neuropraxia secondary to contusion, and sprain of the left ankle. However, the examiner noted that, in a May 13, 2005, ER report, the Veteran did not complain of right shoulder pain or pain in either ankle. His only complaint at that time was related to a contusion on his arm and complaints consistent with ulnar neuropathy. This would suggest that the right shoulder strain and left ankle sprain had essentially resolved by that time. The examiner also commented that it is reasonable that any pain attributed to the arm contusion would have resolved fairly rapidly following the emergency room visit, as recovery from a neuropraxia injury is similarly highly variable with recovery occurring very rapidly or more commonly over the course of a month. However, this would be an unlikely source of significant pain even during the acute phase. The examiner also stated that all of the complaints noted in a neurology consultation of July 21, 2005, could be accounted for by conditions which preexisted the injury that occurred during the May 10, 2005, physical therapy session, with the possible exception of increased paresthesias in an ulnar nerve distribution. The examiner determined that all of the above conditions were self-limited in nature and had healed completely and uneventfully. At the time of the examination, the conditions no longer existed. The examiner further noted that the Veteran sustained a right ankle injury on July 31, 2005, at his home, which involved a stable lateral malleolar fracture and went unreported in the radiology report. However, the examiner stated that the fracture healed. In conclusion, Dr. R.N. determined that it is at least as likely as not that the Veteran did not sustain an injury of the right brachial plexus during the incident in the physical therapy on May 10, 2005. He also stated that there was no injury to the right ankle as a result of this physical therapy session, as records only documented an injury to the left ankle, and the July 31, 2005, injury to the right ankle occurred from a fall at the Veteran's home. Moreover, at the time of the examination, the Veteran had no complaints concerning his left ankle. The examiner stated that it is at least as likely as not that the ankle injury and treatment thereof did not cause the Veteran's current ankle condition. Furthermore, he opined that it is at least as likely as not that the fracture having not been described in the radiology report(s) did not compromise treatment or in any way alter the end result. Dr. R.N. did believe that it is at least as likely as not that the Veteran sustained a contusion to the right arm, strain of the right shoulder, left ankle sprain, and possibly a right ulnar neuropathy as the result of the physical therapy incident of May 10, 2005. However, he also commented that it is at least as likely as not that those injuries and conditions were self-limited and temporary in nature, as they no longer existed at the time of the examination. Moreover, Dr. R.N. observed that medical records documented the Veteran as having had a chronically painful condition of the right shoulder and right upper extremity as well as contractures of the right upper extremity and hand prior to the incident during physical therapy on May 10, 2005. He also had a chronically painful condition of the right ankle prior to the physical therapy incident on May 10, 2005, and the ankle injury sustained at the Veteran's home on July 31, 2005. The examiner opined that it is at least as likely as not that the Veteran's current disability can be accounted for by residuals of a right hemiparesis, including multiple upper extremity contractures; a right brachial plexus injury; a degenerative condition of the cervical spine with right radiculopathy; and, a degenerative condition of the lumbar spine with right radiculopathy. He commented that pre-existing right ankle sprains in December 2004 and earlier may or may not be contributing factors. He also believed that it is at least as likely as not that the Veteran's present complaints of pain and disability would be essentially the same if the May 10, 2005, incident and the July 31, 2005, injury and treatment thereof the had never occurred. Therefore, the examiner stated that it is at least as likely as not that the Veteran's current disabilities represent the natural progression of pre-existing conditions. Dr. R.N. further noted that the Veteran has provided different descriptions of how and when the alleged injuries to the right ankle and right upper extremity occurred. A review of the medical records reveals multiple pre-existing conditions and injuries of the right upper and right lower extremities. The examiner stated that the Veteran's present right brachial plexus condition and right ankle condition were not caused or became worse as a result of VA medical or surgical treatment, VA training, or examination at the Hines VA Medical Center (VAMC). In this regard, the examiner concluded that there is no evidence of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the attending VA personnel. He concluded that the incident that occurred during the May 10, 2005, physical therapy session is a well recognized risk and complication of physical therapy. November 2008 VA Opinion (Dr. R.N.) The Board also notes that the claims file contains a November 2008 VA opinion from Dr. R.N. In that opinion, he indicated that nothing in the medical records had changed or altered his previous opinion. October 2007 VA Opinion (Dr. M.B.J.) With respect to he Veteran's right arm and shoulder, the Board does observe the October 2007 letter from a VA physician, Dr. M.B.J., indicating that the Veteran has been followed in the Neurology Botox Clinic since March 2003. He had been referred for a right spastic hemiparesis that developed following a traumatic brain injury in March 2002. The physician noted that she had evaluated the Veteran on July 21, 2005, in response to a request for a neurology consultation that had been submitted for evaluation of changes in the right arm symptoms following a fall. The Veteran reported that he had fallen in physical therapy on May 10, 2005, in such a way that his right arm or both arms were hanging over some type of support bar. He developed a worsening of pain in the right shoulder when trying to move the arm as well as pains and dysesthesias into the arm to the fingers with increased right wrist flexion and flexion of the proximal interphalangeal joints of the right medial three fingers. EMG studies that were performed a few months later suggested a right lower brachial plexus injury involving the lower trunk. The physician stated that symptoms have gradually improved, but not completely. July 2010 VA Spine Examination (Dr. R.N.) On VA examination in July 2010, the impression was mechanical low back pain, foraminal/central stenosis, and disc protrusion. Dr. R.N. indicated muscle weakness/sensory anomalies would not be related to the spine condition, but rather to the Veteran's brain injury. July 2010 VA Orthopedic Examination (Dr. R.N.) Accompanying x-rays of both ankles showed mild degenerative changes. The diagnoses were right hemiparesis secondary to head injury, multiple contractures of the right upper extremity secondary to the hemiparesis, right brachial plexopathy, and right sinus tarsi impingement syndrome. Dr. R.N. commented that the Veteran's left ankle was asymptomatic; however, x-rays showed some degenerative changes. The right ankle was symptomatic and demonstrated early degenerative changes with injuries, which pre-dated the physical therapy accident. The examiner noted that the Veteran's lateral ankle pain was not directly related to the ankle, but instead was ultimately related to the Veteran's brain injury. He also stated that the multiple contractures of the right upper extremity were secondary to the brain injury, and the shoulder pain was at least in part due to a brachial plexopathy and the brain injury. The examiner determined that there were no physical findings suggestive of an ulnar neuropathy/neuritis. July 2010 VA Opinion (Dr. R.N.) Dr. R.N. stated that is was unclear which ankle the Veteran was claiming he injured during his physical therapy accident; however, the physical therapy note described an injury to his left ankle. The examiner noted that the opinion should be read in conjunction with the VA examinations in July 2010 discussed above. The examiner stated that it was clearly established that the right ankle condition preexisted the physical therapy accident. The examiner also stated that the left ankle condition preexisted the alleged physical therapy injury, as VA medical records in January 2000 show that the Veteran complained of a painful left ankle for four years following a car accident. Dr. R.N. asserted that it is unclear how the low back condition became an issue because there is no indication that the Veteran sustained a back injury during the May 2010 physical therapy incident and that he has a degenerative condition entirely unrelated to the physical therapy incident. As for the right upper extremity, the examiner reiterated that the Veteran had a right hemiparesis and injury to the lower trunk of the brachial plexus, which are due to his motor vehicle accident and not related to the physical therapy incident. As for Dr. M.B.J.'s opinion in October 2007, the Veteran complained of increased muscle tone and increased wrist flexion, which he attributed to the physical therapy incident. However, Dr. R.N. was of the opinion that, if the Veteran did sustain a chronic ulnar nerve injury then in October 2007, he would have had a decrease in muscle tone that could not cause increased wrist flexion, but given that he had a flexion contracture of the wrist, it probably would have had no effect. As for the right ulnar nerve neurapraxia, the examiner found it reasonable that the Veteran sustained an elbow contusion from the fall during the physical therapy session, which may have resulted in ulnar nerve neuropraxia. However, his present symptoms could not be attributed to an ulnar nerve condition, and previous electrophysiological studies in August 2005 document no ulnar nerve pathology. Dr. R.N. believed that the condition resolved at the time of the August 2005 study and may have resolved earlier. He also noted that it is possible that the ulnar neuropraxia never existed, and it may be that the doctors misinterpreted the pre-existing brachial plexus injury as a nerve conduction. Dr. R.N. also reviewed the claims folder and stated that there is no new information that would change his opinion concerning the etiology of the Veteran's right upper extremity condition, which was caused by the closed head injury and brachial plexus injury during the motor vehicle accident. He reiterated his previous opinions in April 2007 that it is more likely than not that the physical therapy incident did not cause nor worsen the right upper extremity condition, bilateral ankle condition, and back condition beyond what would be expected from its natural history. Dr. R.N. noted that it is clear from the medical evidence that there was no back condition at the time of the physical therapy incident in 2005. Additionally, Dr. R.N. commented that he was not aware that written consent is required for physical therapy in any institution with which he has been associated. September 2010 VAMC correspondence An email dated in September 2010 from the VA Medical Center confirmed that there was no consent form found for the Veteran's physical therapy in 2005. August 2011 VA opinion (Dr. R.N.) Dr. R.N. reviewed the claims folder again and reiterated his opinions presented in July 2010. Analysis The Board has thoroughly reviewed all the evidence in the Veteran's claims folders. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). As noted above, in order for a claim pursuant to 38 U.S.C.A. § 1151 to be granted, it must be determined that an additional disability occurred as a result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA. Pursuant to 38 C.F.R. § 3.361, this can be shown by establishing that VA treatment proximately caused additional disability, and that (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care, medical or surgical treatment, or examination without the Veteran's informed consent. On the underlying question of whether the Veteran has any additional disability as a consequence of VA physical therapy treatment in May 2010, Dr. R.N. stated in April 2007 that the Veteran incurred a contusion of the right arm, a strain of the right shoulder, ulnar nerve neuropraxia secondary to contusion, and sprain of the left ankle during the physical therapy incident on May 10, 2005. However, the examiner noted that, in a May 13, 2005 ER report, the Veteran did not complain of right shoulder pain or pain in either ankle. His only complaint at that time was related to a contusion on his arm and complaints consistent with ulnar neuropathy, which would suggest that the right shoulder strain and left ankle sprain had essentially resolved by that time. The examiner also commented that it is reasonable that any pain attributed to the arm contusion would have resolved fairly rapidly following the ER visit, as recovery from a neuropraxic injury is similarly highly variable with recovery occurring very rapidly or more commonly over the course of a month. The examiner also stated that all of the complaints noted in a neurology consultation of July 21, 2005, could be accounted for by conditions that preexisted the injury that occurred during the May 10, 2005, physical therapy session, with the possible exception of increased paresthesias in an ulnar nerve distribution. The examiner determined that all of the above conditions were self-limited in nature and had healed completely and uneventfully. As for the ulnar nerve distribution, the examiner pointed out that the EMG/NCV in December 2005 revealed no residual pathology confined to the ulnar nerve. In July 2010, Dr. R.N. explained that the Veteran's present symptoms could not be attributed to an ulnar nerve condition and previous electrophysiological studies in August 2005 documented no ulnar nerve pathology. Dr. R.N. was of the opinion that the condition resolved at the time of the August 2005 study and may have resolved earlier. Dr. R.N. extensively discussed the Veteran's injuries prior to the physical therapy incident in May 2005, which included injuries sustained during the pedestrian motor vehicle accidents in January 1995 and in March 2002. He attributed the right upper extremity condition, right hand claw deformity, and lower brachial plexus root injury to the pedestrian motor vehicle accident in March 2002. While the Veteran in his statements is unclear as to whether he injured his right ankle or left ankle during the physical therapy incident in May 2005, Dr. R.N. pointed out that the Veteran did not injure his right ankle during the physical therapy incident in May 2005, as the records only show that the left ankle was affected. Dr. R.N. also noted the Veteran had a chronically painful condition of the right ankle prior to the physical therapy incident on May 10, 2005, and subsequently sustained a right ankle injury in his home in July 2005. As for the back, Dr. R.N. indicated the Veteran had lumbar spine stenosis and chronic low back pain with right radiculopathy, which was related to the hereditary and normal aging process of the spine and cannot be attributed to injury sustained during physical therapy. As for degenerative arthritis of the right shoulder, wrist, and ankle, the examiner was of the opinion that these conditions were consistent with an age-related degenerative process and morbidity associated with the hemiparesis due to the motor vehicle accident in March 2002. Dr. R.N. opined that it is at least as likely as not that the Veteran's current disability can be accounted for by residuals of a right hemiparesis, including multiple upper extremity contractures; a right brachial plexus injury; a degenerative condition of the cervical spine with right radiculopathy; and, a degenerative condition of the lumbar spine with right radiculopathy. Dr. R.N. also believed that it is at least as likely as not that the Veteran's present complaints of pain and disability would be essentially the same if the May 10, 2005, incident had never occurred. Therefore, he stated that it is at least as likely as not that the Veteran's current disabilities represent the natural progression of pre-existing conditions. In November 2008, in July 2010, and in August 2011, Dr. R.N. reiterated his opinions and conclusions presented in April 2007. In July 2010, he also noted that the Veteran sustained a left ankle injury during a car accident in 1995. He further stated that it is unclear how the low back condition became an issue, as there is no indication the Veteran sustained a back injury during physical therapy in May 2005. As for the right ulnar nerve neurapraxia, the examiner found it reasonable that the Veteran sustained an elbow contusion from the fall during the physical therapy session in May 2005, which may have resulted in ulnar nerve neuropraxia. However, his present symptoms could not be attributed to an ulnar nerve condition and previous electrophysiological studies in August 2005 documented no ulnar nerve pathology. Dr. R.N. opined that the condition resolved at the time of the August 2005 study and may have resolved earlier. In the instant case, the Veteran submitted an informal claim in September 2005 for compensation under 38 U.S.C.A. § 1151 for a right shoulder and arm injury, ankle injury, and back injury. As discussed above, Dr. R.N. examined the Veteran and extensively reviewed the evidence, and concluded that the Veteran incurred a contusion of the right arm, a strain of the right shoulder, ulnar nerve neuropraxia secondary to contusion, and a sprain of the left ankle during the physical therapy incident on May 10, 2005. Based on the evidence of record, Dr. R.N. further determined that his right shoulder strain and left ankle sprain resolved by May 13, 2005, and any right ulnar nerve neuropraxia resolved by August 2005. The United States Court of Appeals for Veterans Claims has held that, even if a disability resolves itself during the course of a claim, entitlement to benefits may not be denied on the basis that there was no current disability. See McClain v. Nicholson, 21 Vet. App. 319, 323-24 (2007). In the instant case however, the injuries incurred during VA physical therapy treatment in May 2005 all resolved by August 2005, which is prior to the Veteran's claim for benefits received on September 22, 2005. As for Dr. M.B.J.'s opinion in October 2007, she appeared to indicate that the Veteran suffered right arm and shoulder symptoms during the physical therapy incident in May 2005, as he developed a worsening of pain in the right shoulder when trying to move the arm as well as pains and dysthesias into the arm to the fingers with increased right wrist flexion and flexion of the proximal interphalangeal joints of the right medial three fingers. She stated the symptoms improved gradually, but not completely. With regard to medical opinions, the credibility and weight to be attached to a medical opinion are within the Board's province as finder of fact. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The law is clear that it is the Board's duty to assess the credibility and probative value of evidence, and provided that it offers an adequate statement of reasons and bases, the Board may favor one medical opinion over another. Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wray v. Brown, 7 Vet. App. 488 (1995) (the Board may adopt a particular independent medical expert's opinion for its reasons and bases where the expert has fairly considered the material evidence of record). The Board, of course, is not free to reject medical evidence on the basis of its own unsubstantiated medical conclusions. Flash v. Brown, 8 Vet. App. 332 (1995). Greater weight may be placed on one opinion over another depending on factors, such as reasoning employed and whether the examiner was informed of the relevant facts. Nieves Rodriquez v. Peake, 22 Vet. App. 295 (2008). Among the factors for assessing the probative value of a medical opinion are the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Considering the relative merits of the analytical findings and the details of the opinions, the Board places more weight on Dr. R.N.'s opinions because they are supported by a rationale and are detailed and consistent with other evidence of record. While Dr. M.B.J. did note some of the Veteran's history, she did not provide a clear discussion of all of the facts. For example, she did not account for some of the findings prior to the physical therapy incident, such as the May 2003 imaging studies showing extreme osteoporosis of the right shoulder and VA medical records dated earlier in May 2005 documenting treatment for the right shoulder. Moreover, Dr. M.B.J. did not provide any opinion addressing whether an additional disability was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA health care providers who provided physical therapy in May 2005 or whether the additional disability was due to an event that was not reasonably foreseeable. Instead, she simply noted that the Veteran had increased pain that gradually improved, but not completely. Conversely, Dr. R.N.'s opinions were based on medical principles and applied to the facts of the case. Nieves Rodriquez v. Peake, 22 Vet. App. 295 (2008). Dr. R.N. in proffering his opinions considered the nature of the disabilities, the Veteran's history, and relevant longitudinal complaints. Although the Veteran is competent to describe symptoms, such as pain, he contends that he has current disabilities from injuries sustained to his right arm and shoulder, ankle, and back. Under certain circumstances, a lay person is competent to offer an opinion on a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (noting, in a footnote, that sometimes a lay person 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)). Competency is a question of fact, which is to be addressed by the Board. Jandreau at 1377. 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; Layno v. Brown, 6 Vet. App. 465, 69 (1994) (A witness must have personal knowledge in order to be competent to testify to a matter; personal knowledge is that which comes to the witness through the use of the senses.) Whether the Veteran has a current disability due to the fault on the part of VA cannot be determined by the Veteran's own personal knowledge, that is, perceived through the use of his senses. 38 C.F.R. § 3.159; Layno at 469 (a witness must have personal knowledge in order to be competent to testify to a matter; personal knowledge is that which comes to the witness through the use of the senses.). It is not argued or shown that the Veteran is qualified through specialized, education, training, or experience in health care to offer an opinion on whether he has disabilities due to the physical therapy treatment provided by the VA on May 10, 2005, or on the standard of care of a reasonable health care provider, which are factors in determining entitlement to disability compensation under 38 U.S.C.A. § 1151. Indeed, the issues on appeal involve complex medical matters, particularly in light of his prior injuries and disorders that existed prior to the physical therapy incident. For these reasons, the Board rejects the Veteran's lay opinion as competent evidence to substantiate the claims on the question of current disabilities due to fault on the part of VA in providing physical therapy treatment on May 10, 2005. As the Board does not find the Veteran to be competent on these matters, the determination of whether his statements are credible is not reached. The Board acknowledges the Veteran's assertions that he should have been placed in a safety belt; however, Dr. R.N. stated in April 2007 that it is well recognized that patients undergoing physical therapy may sustain an injury related to their therapy. He noted that, for safety precautions, the physical therapy on May 10, 2005, was performed with the protection of parallel bars and that the physical therapy session was well supervised. He commented also that, by the very nature of physical therapy, stresses are often applied to extremities, and it is well recognized that injuries, such as strains and sprains, occur no matter how carefully the rehabilitation program is structured, implemented, and supervised. Dr. R.N. concluded that there is no evidence of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the attending VA personnel. He further stated that the incident that occurred during the May 10, 2005, physical therapy session is a well recognized risk and complication of physical therapy. As Dr. R.N. is qualified through education, training, and experience to offer an opinion on the standard of care provided by VA during physical therapy treatment in May 2005, the Board finds his opinion pertaining to this matter, which is uncontroverted by the other evidence of record, to be more probative than the Veteran's opinion. It is also noteworthy that the Veteran stated that, during the physical therapy incident in May 2005 the therapist left the room, while the incident report shows the therapist was present and assisted the Veteran into an upright position after he slipped. Moreover, even if proper procedure did require the use of a safety belt, the medical evidence must still show that additional disability was incurred as a result of the physical therapy incident. As discussed at length above, the weight of the evidence shows that the Veteran currently has no such additional disabilities. As for informed consent, a signature consent was not required in this case under 38 C.F.R. § 17.32 because this was not a situation causing significant discomfort, risk of complication, or morbidity, and there was no use of sedation, anesthesia, narcotics, or injections of any substance into a joint space or body cavity. See 38 C.F.R. § 17.32 (d). Furthermore, in July 2010, Dr. R.N. stated that he was not aware that written consent is required for physical therapy in any institution with which he has been associated. The Board is sympathetic to the Veteran's health problems. However, the most probative medical evidence of record is against a finding that any additional right shoulder and arm, ankle, and back disability was a result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA health care providers who provided physical therapy on May 10, 2005, nor does the evidence show that there is any additional disability due to an event that was not reasonably foreseeable. Thus, the Board finds that the preponderance of the evidence is against the claims, and the doctrine of reasonable doubt is not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to compensation under 38 U.S.C.A. § 1151 for a right shoulder and arm injury is denied. Entitlement to compensation under 38 U.S.C.A. § 1151 for an ankle injury is denied. Entitlement to compensation under 38 U.S.C.A. § 1151 for a back injury is denied. ____________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs