Citation Nr: 1305199 Decision Date: 02/12/13 Archive Date: 02/21/13 DOCKET NO. 05-26 632 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for a bilateral hand disability with arthritis, including as secondary to the service-connected disability of the cervical spine. 2. Entitlement to service connection for a bilateral wrist disability with arthritis, including as secondary to the service-connected disability of the cervical spine. REPRESENTATION Veteran represented by: Mississippi Veterans Affairs Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from May 1966 to May 1969. He also served in the Air National Guard. This matter is before the Board of Veterans' Appeals (Board) on appeal of an October 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi that in relevant part denied service connection for claimed disabilities of the bilateral hands and bilateral wrists. In July 2005 the Veteran appeared at a hearing before the RO's Decision Review Officer (DRO). A transcript of the hearing is in the Veteran's file. The Veteran currently has a pending claim for total disability rating based on individual unemployability (TDIU), which is the subject of a separate decision because the Veteran is represented by Counsel in regard to that one claim only. In September 2011 the Board remanded these claims to the Originating Agency for further development. As the requested development has been completed, no further action is required to ensure compliance with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. The Veteran does not have a diagnosed disability of the left hand, left wrist or right wrist to include arthritis. 2. Arthritis of the fingers of the right hand was not affirmatively shown to have had onset during service, arthritis is not shown to have been manifested as a chronic disease to a compensable degree within one year after the Veteran's separation from service, arthritis of the fingers of the right hand is not proximately due to or made worse by service-connected disability of the cervical spine.. 3. A disability of the right hand, to include arthritis of the fingers, was not incurred in or aggravated by service and was not caused or permanently worsened by the Veteran's service-connected cervical spine disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a disability with arthritis of the bilateral hands are not met. 38 U.S.C.A. §§ 1110, 1112, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for a disability with arthritis of the bilateral wrists are not met. 38 U.S.C.A. §§ 1110, 1112, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309. 3.310 (2012). 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 a claim. Duty to Notify When VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (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 RO provided pre- and post- adjudication VCAA notice by letters, dated in March 2004 and in September 2011. The notice included the type of evidence needed to substantiate a claim of service connection, including secondary service connection namely, evidence of an injury or disease or event, causing an injury or disease, during service; evidence of current disability; and evidence of a relationship between the current disability and the injury or disease or event, causing an injury or disease, during service; or a connection to a service-connected disability. The Veteran was notified that VA would obtain service treatment records, VA records, and records from other Federal agencies, and that he could submit other records not in the custody of a Federal agency, such as private medical records or with his authorization VA would obtain any non-Federal records on his behalf. The notice included the provisions for the effective date of a claim and for the degree of disability assignable. As for content of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (to the extent of pre-adjudication VCAA notice); of Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim). To the extent that the VCAA notice came after the initial adjudication, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The timing error was cured by content-complying VCAA notice after which the claims were readjudicated as evidenced by the supplemental statement of the case, dated in June 2012. Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The RO has obtained service treatment records, service personnel records, VA records and private medical records. The Board previously reviewed the file and determined additional medical opinion was required to resolve the claims on appeal, and remanded the case for a VA medical examination. VA examinations of the spine, hands, wrists and peripheral nerves were performed in October and November 2011. The Board has reviewed the examination reports and finds the RO substantially complied with the instructions articulated in the Board's remand and no further action to ensure compliance with the Board's remand is required. Stegall v. West, 11 Vet. App. 268 (1998). As the VA examiners considered the Veteran's history and described findings pertinent to the disabilities in sufficient detail so that the Board's decision is fully informed one, the examinations and medical opinions are adequate. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). As there is no indication of the existence of additional evidence to substantiate the claims, no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active military service or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active military service. 38 U.S.C.A. § 1110 (wartime service). Generally, to establish entitlement to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. All three elements must be proved. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). Several legal theories operate in conjunction with 38 U.S.C.A. § 1110 as implemented in 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). For the showing of chronic disease in service there is required 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." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). If a Veteran served 90 days or more on active duty, service incurrence will be presumed for certain chronic diseases, such as arthritis, if manifest to a compensable degree within the year after active service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). Service connection may be granted on a secondary basis for a disability that is proximately due to, or is aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet App. 439 (1995). Evidentiary Standards VA must give due consideration to all pertinent lay and medical evidence in a case where a Veteran is seeking service connection. 38 U.S.C.A. § 1154(a). As the Veteran did not serve in combat, the combat provision of 38 U.S.C.A. § 1154(b) do not apply. Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and weight, factual determinations going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competency is a question of fact, which is to be addressed by the Board. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). When the evidence is admissible, the Board must then determine whether the evidence is credible. "Credible evidence" is that which is plausible or capable of being believed. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (the determination of credibility is a finding of fact to be made by the Board in the first instance). If the evidence is credible, the Board, as fact finder, must determine the probative value or weight of the admissible evidence, that is, does the evidence tend to prove a material fact. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). If the evidence is not credible, the evidence has no probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Evidence The service treatment record shows no indication of injury or disease of the wrists or hands. The Veteran had a separation examination in March 1969, and in a self-reported Report of Medical History he denied a history of arthritis or any painful or deformed bones or joints. The corresponding Report of Medical Examination shows clinical evaluation of the upper extremities as "normal." The Veteran was discharged from service in May 1969. The Veteran had an initial VA examination in November 1969. The examination report is silent in regard to any current complaint of symptoms relating to the hands or wrists. Similarly, the report is silent in regard to any clinically observed abnormality of the hands or wrists, and in fact orthopedic evaluation was cited as negative except for some tenderness and spasm in the cervical spine, without evidence of corresponding loss of muscle strength in the upper extremities. Neurological evaluation was also grossly normal. The Veteran had a National Guard enlistment physical examination in March 1982 in which clinical evaluation of the upper extremities was "normal." The Veteran had a VA examination in January 1983, performed in support of his claim for higher evaluation for his service-connected cervical spine disability. The Veteran complained of pain in the left shoulder and also complained of radiation to the upper arms, but the report is silent in regard to any subjective complaints or any observed clinical abnormality relating to the hands or wrists. The Veteran testified in April 1983 in support of his claim for higher evaluation for his cervical spine disability. The Veteran testified he had pain radiating down the h arms and as well as weakness and tingling in the hands and fingers. He denied actual pain in the hands or fingers, and made no statement regarding the wrists. VA physical therapy notes dated during the period October 1983 to February 1984 show pain and limited motion of the cervical spine, as well as complaint of radiating pain to the upper arms. The physical therapy notes are silent in regard to any limitation of function of the hands or wrists. The Veteran had National Guard periodic physical examinations in January 1986 and November 1989 in which clinical evaluation of the upper extremities was "normal." The Veteran had a VA examination of the neck in December 1992, again in support of a claim for increased rating for the service-connected cervical spine disability. The Veteran complained of weakness in the hands, tingling in the fingers and some aching in the wrists and elbows. During examination the Veteran demonstrated poor grip strength bilaterally but there was no objective sensory or motor pattern. The examiner stated there was no identifiable neurological deficit. The Veteran also had a VA neurological examination in December 1992. The Veteran complained of neck pain into the shoulders but denied pain into the upper extremities. The report is silent in regard to the hands and wrists. The impression was normal neurological examination. The Veteran had a National Guard periodic physical examination in October 1993 in which clinical evaluation of the upper extremities was "normal." The Veteran had a VA examination of the spine in February 1994 in which he described pain radiating from the neck and down the arms to the level of the hands with numbness and tingling of the hands. X-rays of the cervical spine showed arthritis but showed no disc abnormalities. Treatment records associated with the Veteran's National Guard medical records show the Veteran complained of neck and knee pain in December 1994. The hands and wrists were not specifically mentioned. Neurological examinations in April 1994, December 1996, September 1997 and November 1997 essentially showed no neurological deficits associated with the cervical spine disability. Similarly, a VA joints examination in December 1996 is silent in regard to any disability of the hands or wrists. The Veteran had a VA examination of the spine in November 1999 in which he complained of stocking-like decreased sensation from the axilla in the upper extremities. He complained of weakness in all muscle groups in both upper extremities. X-ray of the cervical spine showed osteophytes and slight narrowing of the C5-6 and C6-7 discs. The examiner stated the stocking-like diminished sensation was a nonanatomical finding with no neurologic basis and that the global weakness of all the muscles in both upper extremities would have led to noticeable atrophy, which was not present. The Veteran in fact had well-developed musculature and normal deep tendon reflexes. In light of these nonanatomical responses, the VA examiner concluded that the cervical range of motion demonstrated on examination was not reliable. The Veteran also had a VA neurological examination in November 1999 in which he complained of loss of sensation in hands and weakness in the left upper extremity. Sensory examination demonstrated decreased-to-absent sensation in a diffuse pattern over the hands. Motor examination showed normal motor strength in the right upper extremity, but reduced strength in the left upper extremity. The examiner's impression was significant residuals from cervical spinal cord disease, including in relevant part hyperreflexia in the upper extremities, sensory loss in the h hands and weakness in the left upper extremity. In February 2000 the Veteran complained of pain in the right hand and wrist of three months' duration. X-rays of the right hand and right wrist were unremarkable. The clinical impression was to rule out carpal tunnel syndrome. The Veteran had a VA neurological examination in February 2001 that is silent in regard to abnormalities of the hands and wrists. The examiner characterized neurological examination as unremarkable. VA records show that in October 2001 the Veteran complained of pain over the upper extremities. After magnetic resonance imaging (MRI) of the cervical spine, the impression was probable cervical radiculopathy. The Veteran had a VA neurological examination in November 2001 in which the upper extremities showed no motor or sensory loss. The examiner noted the right upper extremity was difficult to assess because the Veteran was wearing a wrist splint secondary to carpal tunnel syndrome, but there was no evidence of atrophy or weakness in the right forearm or upper arm. In April 2002, the Veteran complained of weakness and paresthesias in the arms. Clinical examination showed no atrophy of the upper extremities. The clinical impression was pain in the arms. VA records show that in December 2002 the Veteran stated that he hit left index finger with a hammer. X-rays showed a minimally displaced fracture involving the second digit (index finger) of the left hand. In February 2003, the Veteran testified that the pain and stiffness in the right wrist had progressed to the point where he could not use his right hand for writing or for driving a car. In June 2003, the Veteran complained f right hand pain and cramping. An EMG study had shown normal right upper extremity, but the Veteran's complaints continued. In September 2003, the impression was degenerative joint disease with worsening pain in the hands. X-rays of the hands showed only a small posttraumatic calcific density on the left index finger; otherwise there were no significant abnormalities of the hands. In November 2003, the Veteran testified hat he had arthritis of the right hand to such a degree that he was unable to hold a pencil or brush his teeth. He testified that his arthritis of the right hand was caused by his service-connected cervical spine disability. VA records in December 2004 show that Veteran complained of continued chronic neck pain, but denied current weakness or numbness in the upper extremities. In January 2005, sensory examination of the upper extremities was symmetrical and all reflexes were normal. In February and in May 2005, the Veteran complained of chronic multiple joint pains, especially in the neck and hands. The impression was chronic pain secondary to degenerative joint disease. In July 2005, the Veteran asserted he had been told by his VA physician that his current arthritis of the hands and wrists was secondary to the service-connected disability of the cervical spine. VA records show that in September 2005 the Veteran complained that the fingers of his right hand would "lock up" when writing. No abnormality of the fingers was found. There was reference to an X-ray of the right hand, which showed degenerative changes in the proximal interphalangeal (PIP) joint of the thumb, but the bony architecture of the hand was otherwise normal and no soft tissue abnormality was seen. In November 2005, the Veteran continued to complain of chronic joint pain, especially in the neck and hands. The continued impression was chronic pain secondary to degenerative joint disease.DJD. In May 2006, the Veteran was examined for his claim for Social Security Administration (SSA) disability benefits. The Veteran stated that he had taken medication for 15 years for arthritis in the hands and knees. On examination, there was no bone or joint abnormality. The motor and sensory examinations were intact. There was no diagnosis of a hand or wrist abnormality. On VA examination in December 2008, the Veteran complained of numbness and tingling in the hands and pain radiating from his neck into his right hand. On examination the upper extremities had normal muscle tone and bulk. Strength was 5 of 5 in all major muscle groups except the fifth (little) fingers, which were 4 of 5. The Veteran had normal ability to make a fist and normal grip strength bilaterally. He could oppose thumb to fingers in each hand. Sensation to pinprick was diminished in all fingers and in both forearms in no specific dermatonal pattern. Two-point discrimination was impaired in the fourth and fifth fingertips of the hands. The deep tendon reflexes were 2+ and symmetrical, and there was no wrist clonus. The diagnosis was possible mild bilateral C8-T1 radiculopathy. On VA examination in October 2011, the Veteran complained of right wrist pain, beginning in 1999, when he was told that he had arthritis. He denied complications of the left wrist. X-rays of the wrists showed no pathology. The VA examiner stated that the Veteran's complaints of right wrist pain were subjective in nature with no clinical evidence of pathology including arthritis. Because no medical diagnosis regarding the right wrist could be rendered, the VA examiner stated that it was less likely than not that the right wrist pain was related to the service-connected disability of the cervical spine. As for the left wrist, no opinion could be rendered because the Veteran had no subjective complaints and there was no diagnosis. On VA examination in October 2011, the Veteran complained of pain, stiffness, weakness and locking of the fingers in his right hand. He denied problems with the fingers of his left hand. X-rays showing gouty arthritis in the fingers of the right hand. The diagnosed was right joint pain and arthritis in the first through third metacarpophalangeal (MCP) and PIP joints and gouty arthritis in the right first and fifth fingers. The examiner stated that the arthritis was less likely than not caused or aggravated by the service-connected cervical spine disability. On VA examination in November 2011, the Veteran denied having trouble with the left hand, but he complained of pain in the right wrist and of locking of the fingers in his right hand. All nerve groups of the upper extremities were normal on examination. The VA examiner noted that motor strength was 5 of 5. Tone, bulk, dexterity and coordination were normal. Sensory was intact to fine touch, vibration and position. A MRI showed a rotator cuff tear in the right shoulder. X-ray of the right wrist was normal, but X-rays of the right hand showed degenerative joint disease. The examiner stated the Veteran had no motor or sensory deficits referable to the service-connected cervical spine disability. The Veteran's hand cramps were not suggestive of a cervical lesion. There was EMG evidence of right ulnar neuropathy, but the VA examiner explained that a spinal root problem could not cause ulnar neuropathy and the ulnar neuropathy was unrelated to the service-connected cervical spine disability. The VA examiner stated that while there was evidence of extensive cervical disc disease with radiculopathy there was no medical evidence suggesting that the cervical disability caused or accelerated the development of degenerative spine and disc disease and therefore it was unlikely that the service-connected disability was caused the current hand or wrist disability or aggravated a nonservice-connected condition. In April 2012, the Veteran's wife stated that the Veteran experienced excruciating pain radiating from the neck to the arms and wrists and that on occasion he required assistance with everyday activities, such as bathing, shaving, eating, and dressing. She stated that on occasion the Veteran was unable to drive or to hold objects in his hands due to muscular contractions in the hands and fingers. She stated she sometimes had to massage the Veteran's hands and fingers to afford him some relief. Analysis 38 C.F.R. § 3.303(a) (Affirmatively Showing Inception in Service) The service treatment record does not show, and the Veteran does not assert, that he had any hand or wrist symptoms that were treated during service. Service connection under 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303(a) (affirmatively showing inception in service) is therefore not established. 38 C.F.R. § 3.303(b) (Chronicity and Continuity of Symptomatology) For the showing of a chronic disability in service there is required a combination of manifestations sufficient to identify the disability and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b); See Savage v. Gober, 10 Vet. App. 488, 497 (1997) (chronicity requires evidence that the disability was present in service and the same condition currently exists, such evidence must be medical, unless the disability is one under case law that is capable of lay observation.). Establishing service connection based on continuity of symptoms requires (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. See Savage, 10 Vet. App. at 494-97 (continuity of symptomatology requires that the evidence either contemporaneous with service or otherwise show only that a condition was observed, that is, noted, during service); see Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (continuity of symptoms requires evidence of a nexus between the current disability and the post-service symptoms, which are identical to the symptoms that began in service). As the service treatment record lacks the documentation of the combination of manifestations sufficient to identify the condition that currently exists, namely, degenerative joint disease of the fingers of the right hand, and as there was insufficient observation to establish chronicity at the time, on the basis of a normal evaluation on separation examination and normal examinations in Air National Guard service for many years after discharge from service, chronicity since service, to include chronicity of symptomatology, is not adequately supported by the evidence of record. Although service connection is not established either by chronicity or by continuity of symptomatology on the basis of lay evidence under 38 C.F.R. § 3.303(b), service connection may still be established based on an initial diagnosis after service under 38 C.F.R. § 3.303(d). 38 C.F.R. § 3.303(d) (Disability First Diagnosed after Service) The Veteran is shown to have developed a disability of the fingers of the right hand after discharge from service. However, he is not shown to have any diagnosed disability of the left hand or the left wrist or right wrist. As for the right wrist, although the Veteran has complained of pain, pain alone without a diagnosed or identifiable underlying pathology does not constitute a disability for which service connection can be granted. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). In the absence of any diagnosed disability of the left hand, left wrist, or right wrist, as a threshold matter that the Veteran has not presented claims for which service connection can be considered. In the absence of a proof of present disability, there are no valid claims of service connection for a left hand, left wrist, or right wrist disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). On the claim of service connection for right hand disability, arthritis of the fingers of the right hand has been demonstrated. There is no medical evidence relating a right hand disability directly to service, and the Veteran does not assert his right hand symptoms began during service. Accordingly, entitlement to service connection for a right hand disability under 38 C.F.R. § 3.303(d) is not shown. 38 C.F.R. § 3.307 and 3.309(a) (Presumptive Service Connection for Arthritis) Degenerative joint disease or arthritis by X-ray was first shown in 2003, well beyond the one-year presumptive period following separation from service in 1969 for manifestation of arthritis as a chronic disease under 38 U.S.C.A. § 1112 and 38 C.F.R. §§ 3.307, 3.309. 38 C.F.R. § 3.310 (Secondary Service Connection) The Veteran does asserts his right hand disability, diagnosed as degenerative joint disease or arthritis in the fingers, is due to or aggravated by his service-connected cervical spine disability. The Veteran is competent to describe right hand pain, stiffness, weakness, and similar observable symptoms. See 38 C.F.R. § 3.159 (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.); see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (Lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses). To this extent, the Veteran's lay statements of right hand symptoms since service are competent evidence of post-service onset and continuity of symptomatology. Similarly, the statement of the Veteran's wife is competent to describe observed symptoms relating to the hands. However, it does not necessarily follow from the lay evidence of record that there is a relationship between the post-service right hand disability and the service-connected cervical spine disability. Medical evidence is required to demonstrate such a relationship, unless such a relationship is one to which the Veteran as a lay person is competent. The question then is whether the Veteran as a lay person is competent to offer an opinion on the causal relationship or nexus between the current disability and the service-connected cervical spine disability. Jandreau at 1377. Degenerative joint disease or arthritis in the fingers is not a condition under case law that has been found to be capable of lay observation, and it is not a simple medical condition, because the disability cannot be identified or diagnosed by the Veteran as a lay person based on mere personal observation. That is, the disability cannot be perceived through the senses, for example. by visual observation, and therefore such a disability is not a simple medical condition. As the disability is not a condition that can be identified based on personal observation, either by case law or as a simple medical condition, any inference based on what is not personally observable cannot be competent lay evidence. No factual foundation has been established to show that the Veteran is otherwise qualified through specialized education, training, or experience to offer an opinion on the causal relationship or nexus between the current right hand disability and his service-connected cervical spine disability as the Veteran avers. For this reason, the Veteran's lay opinion is not competent evidence of a causal relationship or nexus between the current disability and the service-connected disability. Since the Veteran's lay opinion is not competent evidence, his opinion is excluded, that is, not admissible as evidence and cannot be considered as competent evidence of nexus favorable to claim based on secondary service connection. As for the competent medical evidence, that is, evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion, 38 C.F.R. § 3.159, and as the competency of a VA examiner is presumed, absent a showing of evidence to the contrary, Hilkert v. West, 12 Vet. App. 145 (1999), the competent and uncontroverted medical opinions of record, in the form of VA examinations in October and November 2011, show that the Veteran's claimed right wrist disability is not caused by or aggravated by the service-connected disability of the cervical spine. The findings of a physician are medical conclusions that the Board cannot ignore or disregard. Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board finds that the medical opinions of the VA examiners are persuasive evidence against the claim. As the preponderance of the medical evidence is against the claim of service connection for the right hand, the benefit-of-the-doubt standard of proof does not apply and service connection is not warranted. (The Order follows on the next page.). ORDER Service connection for a disability of the bilateral hands is denied. Service connection for a disability of the bilateral wrists is denied. ____________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs