Citation Nr: 1306736 Decision Date: 02/27/13 Archive Date: 03/01/13 DOCKET NO. 09-35 365 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for osteoarthritis of the hands and fingers. 2. Entitlement to service connection for arthritis of the left elbow. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his son ATTORNEY FOR THE BOARD E. Woodward Deutsch, Counsel INTRODUCTION The Veteran served on active duty from April 1944 to February 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), that denied entitlement to service connection for osteoarthritis of the hands and fingers and arthritis of the left elbow, each claimed as due to cold injuries. In November 2010, the Veteran testified at a Travel Board hearing before the undersigned Acting Veterans Law Judge. A copy of the hearing transcript has been reviewed and associated with the claims file. In January 2011 and April 2011, the Board remanded the Veteran's claims for additional evidentiary development. Thereafter, in August 2012, the Board determined that an expert medical opinion from a health care professional in the Veterans Health Administration (VHA) was necessary to address the complex medical questions raised in the appeal. 38 C.F.R. § 20.901(a), (d) (2012). In November 2012, the requested VHA opinion was received by the Board and a copy was sent to the Veteran. At that time, the Board advised the Veteran that he had 60 days to review the VHA opinion and submit additional evidence in connection with his claims. In response, the Veteran's service organization representative submitted written argument, dated January 2013, which has been considered in this appeal. No further evidence has been received. As discussed in further detail below, the Board finds that there has been substantial compliance with its prior remand directives and, thus, appellate review may proceed. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Moreover, while cognizant that neither the VHA opinion nor the ensuing argument from the service representative has been reviewed by the agency of original jurisdiction, a waiver of AOJ review by the Veteran is not required under these circumstances. See 38 C.F.R. §§ 20.903(a), 20.1304(c) (2012). In addition to reviewing the Veteran's paper claims file, the Board has surveyed the contents of his Virtual VA efolder. The Board is obligated to consider the additional evidence contained therein since, under VA's current guidelines, such evidence is considered part of the constructive record. See Bell v. Derwinski, 2 Vet. App. 611 (1992) (holding that VA treatment records are in the constructive possession of the agency, and must be obtained if material to a claim); see also Veterans Benefits Administration Fast Letter 11-28 (outlining revised procedures related to electronic records). Nevertheless, the Board concludes that the Veteran's Virtual VA efolder is devoid of any additional evidence that is material to the current appeal and, thus, need not be further addressed at this time. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The weight of the competent and credible evidence does not show that the Veteran's currently diagnosed osteoarthritis of the hands and fingers was caused or aggravated by cold weather exposure or other injuries incurred during his recognized combat service in World War II. Nor does the evidence reflect that this current disability manifested to a compensable degree within one year of the Veteran's separation from the Army is otherwise related to his active service, including his service-connected lower extremity cold weather residuals. 2. The weight of the competent and credible evidence does not show that the Veteran's currently diagnosed left elbow arthritis was caused or aggravated by cold weather exposure or other injuries incurred during his recognized combat service in World War II. Nor does the evidence reflect that this current disability manifested to a compensable degree within one year of the Veteran's separation from the Army is otherwise related to his active service, including his service-connected lower extremity cold weather residuals. CONCLUSIONS OF LAW 1. The requirements for service connection for bilateral hand and finger osteoarthritis have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. The requirements for service connection for left elbow arthritis have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the VCAA notice requirements apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is established. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the AOJ. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, the VCAA notice provisions were satisfied through a January 2008 letter, which advised the Veteran of the evidence needed to substantiate his service connection claims, as well as the division of responsibilities that he and VA shared in developing the appeal. That letter also explained the types of information and evidence needed to establish a disability rating and an effective date, even though such notice has now been rendered moot by the Board's decision to deny the claims herein. In light of the above VCAA notice letter, which was sent prior to the July 2008 rating decision on appeal, the Board finds that no further development is required with respect to the duty to notify. Regarding the duty to assist, the Board observes that VA has obtained the Veteran's in-service personnel and treatment records, as well as his pertinent VA outpatient treatment records. Significantly, the Veteran has not contended, and the record has not otherwise shown, that any treatment records remain outstanding that are necessary to decide his claims. Moreover, while the record reflects that the Veteran is no longer working, he has acknowledged that his retirement was age-related and has not professed to have applied for or received disability benefits from the Social Security Administration (SSA). Accordingly, VA is not required to assist the Veteran in obtaining SSA records as no reasonable possibility exists that such assistance would aid in substantiating his claims. 38 U.S.C.A. § 5103A(c)(1); Golz v. Shinseki, 590 F.3d 1317, 1321-22 (Fed. Cir. 2010). In addition to the foregoing in-service and post-service records, VA has elicited other clinical and lay evidence pertinent to this appeal. Such evidence has included VA examination reports, obtained pursuant to the Board's prior remands; a VHA expert medical opinion; and written statements and testimony from the Veteran and his son. As discussed below, the inadequacies inherent in the VA examination reports have been effectively remedied by the opinion from the VHA expert examiner. Despite expressing dissatisfaction with the conclusions drawn by that examiner, the Veteran has not alleged, and the record does not otherwise suggest, that the VHA opinion was inadequate to rate his claims. Barr v. Nicholson, 21 Vet. App. 303 (Fed. Cir. 2007). As such, the Board considers it unnecessary to remand for a new examination or opinion in support of those claims. The Board also considers it unnecessary to remand those claims for another hearing before a Veterans Law Judge as the Veteran has already been afforded a hearing before the undersigned. 38 C.F.R. § 20.700(a). In this regard, the Board is cognizant of the decision of the United States Court of Appeals for Veterans Claims (Court), which held that 38 C.F.R. § 3.103(c)(2) imposes on a VA hearing officer (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked). Bryant v. Shinseki, 23 Vet. App. 488 (2010). Moreover, the Board is particularly mindful of the recent legal changes regarding the obligations of Veterans Law Judges who preside at hearings to (1) fully explain the issues and (2) suggest the submission of evidence that may have been overlooked. Id.; 38 C.F.R. § 3.103(c)(2). Nevertheless, the Board observes that these additional due process requirements have been effectively abrogated by the adoption of a final rule "amending [VA's] hearing regulations to clarify that the provisions regarding hearings before the [AOJ] do not apply to hearings before the [Board]." See Rules Governing Hearings Before the Agency of Original Jurisdiction and the Board of Veterans' Appeals; Clarification, 76 Fed. Reg. 52572 (Aug. 23, 2011) (clarifying that 38 C.F.R. § 3.103 does not apply to Board hearings). While that final rule was initially repealed, it has now been reinstated, effective June 18, 2012. Even if the Board assumes that the above rule is not for application and that Bryant still has bearing on the Veteran's claims, there is no reason to delay adjudication for purposes of ensuring compliance with that precedential decision. That is because the Veteran has not contended, and the evidence does not otherwise show, that the VA officer who presided over his November 2010 Travel Board hearing committed prejudicial error, either by failing to adequately apprise the Veteran of the issues presented or by neglecting to suggest the submission of helpful evidence that may otherwise have been overlooked. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.103(c)(2); Bryant, 28 Vet. App. at 296. Moreover, there is no indication that the Veteran was otherwise denied due process during his Travel Board hearing. Further, the Board considers it significant that, although that hearing preceded Bryant and, thus, did not include a specific recitation of the bases for the prior adjudication or the elements that were lacking to substantiate the claims, the Veteran and his representative displayed actual knowledge of this information. Indeed, their filings have specifically referred to the pertinent evidence of record, and the applicable laws and regulations, in arguing that the Veteran has met the criteria for service connection for his current upper extremity arthritis disorders. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim). Therefore, even presuming, without conceding, that the Veteran's November 2010 hearing did not fully comply with the Bryant provisions, such error was harmless in light of the actual knowledge of these provisions demonstrated throughout the appeals period. 38 C.F.R. § 3.103(c)(2). In light of the foregoing, the Board finds that the AOJ has substantially complied with the January 2011 and April 2011 remand directives such that no further action is necessary in this regard. See D'Aries, supra. Moreover, the Board finds that VA has fully satisfied the duty to assist in this instance. Indeed, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Service Connection The Veteran contends that his current upper extremity disorders - diagnosed as osteoarthritis of bilateral hands and fingers and arthritis of the left elbow - had their onset during World War II. Specifically, he professes that, while serving as an infantry machine gunner during the Battle of the Bulge, he injured his upper extremities through frostbite and repeated jumps into foxholes. Those in-service injuries, the Veteran now maintains, permanently damaged his hands, fingers, and left elbow, resulting in pain, weakness, and loss of dexterity that have progressively worsened over time. The Veteran's account of combat-related trauma is corroborated by his service personnel records, which confirm that he received both the World War II Victory and Purple Heart Medals. In view of that objective recognition of the Veteran's combat service, the Board will consider his claims for direct service connection under the evidentiary standards set forth in 38 U.S.C.A. § 1154(b). Additionally, given that the disabilities on appeal fall into the category of chronic diseases and reportedly share the same etiology as the Veteran's service-connected lower-extremity cold weather residuals, the Board will also consider whether service connection is warranted on a presumptive or secondary basis. 38 C.F.R. §§ 3.307, 3.309, 3.310; see Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) (noting that Board is required to consider all theories of entitlement raised either by the claimant or by the evidence of record). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). The second and third requirements may be satisfied with evidence of a chronic disease shown during service or a continuity of symptomatology. See 38 C.F.R. § 3.303(b); see Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). When, as in the instant case, there is evidence that the Veteran engaged in combat, satisfactory lay or other evidence of an injury sustained in the line of such duty shall be accepted as sufficient proof of in-service incurrence if the evidence is consistent with the circumstances of service, even when there is no official record of service incurrence of the injury. 38 U.S.C.A. § 1154(b) (West 2002). However, competent evidence demonstrating present disability or a nexus between such disability and some remote injury or disease of active service is still required. See Cohen (Douglas) v. Brown, 10 Vet. App. 128, 138 (1997) ("[s]ection 1154(b) provides a factual basis upon which a determination can be made that a particular disease or injury was incurred or aggravated in service but not a basis to link etiologically the condition in service to the current condition"). For arthritis and other chronic diseases shown in service, subsequent manifestations at any later date, however remote, are presumed to be service-connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. However, if chronicity in service is not established or where the diagnosis of chronicity may be legitimately questioned, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, arthritis and certain other chronic diseases, listed in 38 C.F.R. § 3.309(a), may be presumed to have been incurred in service if manifested to a compensable degree within one year of separation. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability, which includes the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995). To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b). The Board notes that VA amended its regulation pertaining to secondary service connection, effective October 10, 2006. See 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310). The amendment appears to place additional evidentiary burdens on claimants seeking service connection based on a theory of aggravation; specifically, in terms of establishing a baseline level of disability for the non-service-connected condition prior to the aggravation. In this regard, the Board acknowledges the precedential case law holding that revised regulations cannot be applied to pending claims if they have impermissibly retroactive effects. See, e.g., Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Nevertheless, the Board finds that this holding is not applicable to the instant appeal, which arose following the enactment of the regulatory change at issue. Next, the Board observes that the Veteran, as claimant, bears the "evidentiary burden" of establishing all elements of his claim, including the nexus requirement. Fagan v. Shinseki, 573 F. 3d 1282, 1287-88 (2009). However, it is the Board's duty is to duly consider all pertinent medical and lay evidence, submitted by the Veteran or otherwise of record, and to assign such evidence probative weight in accordance with its credibility and competency. See Dalton v. Nicholson, 21 Vet. App. 23, 36 (2007); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ('a legal concept determining whether testimony may be heard and considered') and credibility ('a factual determination going to the probative value of the evidence to be made after the evidence has been admitted'). Moreover, in circumstances where there is an approximate balance of positive and negative evidence, the Veteran is to be afforded the benefit of the doubt. Fagan, 573 F.3d at 1287 (quoting 38 U.S.C.A. § 5107(b)). Furthermore, the Board may not ignore or disregard any medical professional's opinion, but may favor one such opinion over another by providing an adequate statement of reasons or bases. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Willis v. Derwinski, 1 Vet. App. 66, 70 (1991). Factors for discerning the probative value of medical opinion evidence included whether the opinion factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In making all determinations, the Board must also fully consider the lay evidence of record. This includes any evidence not requiring that the proponent have specialized education, training, or experience. Such evidence will be deemed 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(a). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Kahana, 24 Vet. App. at 433; Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). For instance, a lay person may speak to etiology in those limited circumstances where a nexus is obvious merely through observation, such as a fall leading to a broken leg. Jandreau, 492 F.3d 1372, 1376-77. In order to be considered probative for VA rating purposes, the lay evidence submitted by a Veteran must not only be competent but also credible. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The Board now turns to the pertinent evidence at issue in this appeal. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (discussion of all evidence by the Board is not required when the Board has supported its decision with thorough reasons and bases regarding the relevant evidence). The Veteran's service treatment records, including the reports of his March 1944 enlistment and January 1946 separation examinations, reveal that he was presumed sound at entry but later discharged after incurring a gunshot wound to the left hip. However, those service records are devoid of any complaints or clinical findings of cold weather injuries or falls incurred in combat. Nor do those records contain any other evidence of hand, finger, or elbow problems. Nevertheless, the Board considers the Veteran's assertions of active-duty injuries to his upper extremities to be consistent with the circumstances of his documented combat service. Thus, affording the Veteran the benefit of the doubt, the Board accepts his account of such in-service injuries, notwithstanding the lack of official confirmation. 38 U.S.C.A. § 1154(b); Cohen, supra. However, in order to prevail in his claims for service connection, he must still demonstrate an etiological link between those in-service injuries and current disabilities. In written statements and Board testimony, the Veteran has reported chronic discomfort, numbness, tingling, and related symptoms in his fingers, hands, and left elbow. He has acknowledged foregoing treatment for many years, but has nonetheless maintained that such symptoms have persisted on a continuous basis since service. The Veteran's son also has submitted testimony attesting to the Veteran's long-term sensitivity to cold, as well as his difficulties holding screwdrivers and performing other tasks that require manual dexterity. The account of continuous upper extremity symptoms since service, proffered by the Veteran and his son, is at odds with statements that the Veteran made earlier in the appeals period. During the initial May 2008 VA examination conducted in support of his claims, he expressly acknowledged that he had experienced only intermittent upper extremity problems after leaving the Army and that such problems had not become "very noticeable" until the mid-1980s. The Veteran further conceded that the frostbite he had incurred in service had been worse in his feet than in his hands. Contemporaneous physical testing and X-rays were negative for any evidence of traumatic arthritis arising from fractures. Instead, the clinical findings obtained therein were found to comport the diagnosis of mild osteoarthritis in the Veteran's hands and fingers. The examining VA clinician noted that such minor degenerative changes were "more than likely concurrent with [the] aging [process]," but ultimately stated that he could not determine without resorting to speculation whether the Veteran's bilateral hand condition was, in fact, age-related or whether it had begun in service. The May 2008 VA examiner's report did not include any findings regarding the Veteran's elbows. This deficiency prompted VA to request an addendum opinion, which was completed in September 2009. The addendum included a review of the evidence summarized above as well as recent X-rays, which showed the Veteran's elbows to be normal, bilaterally, with the exception of "very minimal" left-sided osteoarthritic changes. The VA examiner opined that such changes were "more than likely age developmental and not consistent with the pattern related to cold injury residuals." Conversely, the examiner opined that the peripheral neuropathy and related symptoms affecting the Veteran's lower extremities were definitively related to his cold weather exposure in service. In subsequent Board testimony, the Veteran complained that the May 2008 VA examination had focused inordinately on his lower extremities. He further alleged that neither that examination nor the September 2009 addendum had sufficiently accounted for his lay assertions of continuous upper extremity symptoms arising from his in-service cold weather injuries. The Veteran's allegations prompted the Board to remand his claims for a follow-up VA examination that would be predicated on the entire record, but would place particular emphasis on his account of pain and discomfort in his hands, fingers, and left elbow since active service. Before such an examination could be conducted, however, the Veteran underwent a December 2010 VA cold injuries examination in which he reported ongoing pain, numbness, tingling, and stiffness in his hands and fingers. However, that examination, like the one conducted in October 2008, concentrated primarily on the Veteran's lower extremities and did not yield a definite nexus opinion with respect to any upper extremity disorders. The VA examination requested by the Board took place in January 2011. At that time, the Veteran reiterated his account of in-service cold weather injuries involving his hands and feet. In contrast with prior examinations, however, he also claimed to have injured his hands and left elbow by jumping into foxholes while carrying a rifle during combat missions. Nevertheless, the Veteran continued to deny any significant upper extremity pathology prior to the mid-1980s. He added that, since that time, his symptoms had progressively worsened and now consisted of upper extremity pain, stiffness, and weakness, which reoccurred daily and were aggravated by cold weather exposure. As with the May 2008 VA examination, physical testing and X-rays did not yield any signs of fractures or other evidence of traumatic arthritis. Instead, only degenerative changes consistent with aging were shown. Based on those objective findings, and a review of the claims file, the January 2011 VA examiner determined that the Veteran's current upper extremity pathology warranted diagnoses of osteoarthritis of the hands and fingers and arthritis of the left elbow. The examiner added that it was less likely than not that either of those current conditions was service-related. As a rationale for that opinion, the examiner noted that not only were those conditions indicative of the "progressive arthritis of aging," but that it also was "unlikely that the [in-service] injuries described [by the Veteran] would have been of sufficient severity so as to result in post-traumatic arthritis" persisting until the present day. Following another remand by the Board, the January 2011 VA examiner rendered an April 2011 addendum opinion, elaborating on his prior findings in the context of the Veteran's own reports of long-standing pain in his hands, fingers, and left elbow. Such complaints, the VA examiner noted, were "not very reliable" as the Veteran was not able "to specify when he actually started to have symptoms of pain in his hands and elbow," nor describe in detail the progression of those symptoms. Accordingly, the examiner reaffirmed his prior opinion that the Veteran's bilateral hand and finger osteoarthritis and left elbow arthritis were degenerative in nature - due to "wear and tear" of the joints - and were less likely than not caused by or the result of cold injuries or any other aspect of his active service. The record thereafter shows that, in an effort to afford the Veteran the maximum opportunity to prevail in his appeal, the Board forwarded his claims file to a hand surgeon for a VHA expert medical opinion. The Board specifically requested that the VHA examiner accept as true the Veteran's reported in-service history of cold weather exposure as well as his post-service history of pain and discomfort in his hands, fingers, and left elbow. In response to the Board's request, the designated VHA examiner reviewed the Veteran's claims file and rendered an October 2012 opinion affirming the negative nexus findings contained in the 2009 and 2011 examination reports. In this regard, the VHA examiner did not dispute the Veteran's account of in-service cold weather injuries, but concluded that it was "unlikely that cold exposure alone would [have] result[ed] in [the] focal joint arthritis" that later manifested in his upper extremities. The VHA examiner added that cold exposure was also unlikely to have caused generalized arthritis of the hands or even isolated left elbow arthritis. Nevertheless, the VHA examiner acknowledged that the asymmetric index finger distal interphalangeal (DIP) motion and the asymmetric left elbow range of motion, noted by the 2011 BA examiner, "may have been the result of a blunt traumatic injury directly to th[o]se joints." However, the VHA examiner noted that more detail would be necessary in order to positively relate those particular joint manifestations to the Veteran's reports of jumping into foxholes while carrying a rifle in combat. In this regard, the VHA examiner commented that the Veteran's "recounting of the exact mechanism by which, while in combat, he was carrying his rifle while jumping into a foxhole and, specifically, of whether he sustained a direct impact to these affected joints, would be important in determining and/or revealing whether this event included a casually related injury resulting in the development of the [current upper extremity] joint contractures." Despite allowing for that possibility, the VHA examiner stressed that the Veteran's "DIP arthritis was the most common site of arthritis in the hands and [was] frequently idiopathic," as opposed to trauma-related. The examiner further opined that there was nothing in the Veteran's aforementioned September 2009 left elbow X-rays that suggested asymmetric posttraumatic arthritis consistent with a prior blunt injury. As noted in the introduction, the Board forwarded a copy of the VHA examiner's October 2012 report to the Veteran, thereby affording him the opportunity to comment in greater detail on the nature of the traumatic injury he had incurred by jumping into foxholes during combat service. However, notwithstanding the VHA examiner's notation that such additional comment would be instrumental in deciding the issues on appeal, the Veteran declined to elaborate. Nor did he submit any other evidence in support of his claims or provide information that would enable VA to obtain such evidence on his behalf. Consequently, the Board finds that, to the extent the additional comment requested by the VHA examiner, or any other favorable evidence, was not obtained, the responsibility lies with the Veteran. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (VA's duty to assist is not a one-way street.) Based on a careful review of the foregoing evidence, the Board finds that service connection for the Veteran's bilateral hand and finger osteoarthritis and left elbow arthritis is not warranted. In reaching this conclusion, the Board relies heavily on the VHA examiner's opinion that the symptoms underlying the Veteran's currently diagnosed bilateral hand and finger osteoarthritis and left elbow arthritis are less likely than not related to the cold exposure and traumatic jumps he incurred in service. The Board considers that opinion to be more probative than the findings rendered by any of the previous VA examiners. See Wensch v. Principi, 15 Vet. App. 362, 367 (2001) (In its assessment of medical evidence, the Board can favor some medical evidence over other medical evidence so long as the Board adequately explains its reasons for doing so.) In making this determination, the Board has considered whether the respective examiners were 1) fully informed of the pertinent factual premises (i.e., history) of the case; 2) provided a fully articulated opinion; and 3) supported that opinion with a detailed analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). With regard to the first prong of this three-part inquiry, the Board recognizes that the VA examiner who authored the May 2008 report and the September 2009 addendum professed to have reviewed the entire claims file. However, as noted in the Board's prior remand, he did not sufficiently account for the Veteran's assertions of in-service cold weather injuries. Nor did that examiner consider the Veteran's description of upper extremity trauma incurred by jumping into foxholes. Indeed, such lay evidence was not introduced until after the May 2008 report and the September 2009 addendum were completed. Nevertheless, the authors of the subsequent December 2010 and January 2011 VA examination reports, and the April 2011 addendum, also failed to account for the lay evidence of in-service injuries incurred from cold weather exposure and traumatic jumps. Moreover, those clinicians, like the initial VA examiner, declined to adequately weigh the Veteran's descriptions of ongoing upper extremity pain, numbness, and related symptoms persisting since service. As discussed above, the Veteran's account of injuries incurred from cold exposure and traumatic jumps, while not corroborated by his service treatment records, is nonetheless consistent with the circumstances of his combat service and, thus, is accepted as true. 38 U.S.C.A. § 1154(b) (West 2002). Moreover, the Veteran is accepted as competent to describe a continuity of post-service pain and discomfort in his upper extremities, which are capable of lay observation. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). His son is also deemed competent to report a continuity of symptomatology that he has personally witnessed in the Veteran. Id. Further, while both parties' credibility has been called into question, for the reasons set forth below, this does not exempt their statements from consideration by the prior VA examiners. On the contrary, determinations of credibility fall within the province of the Board as fact-finder. See Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). As such, it is the responsibility of VA examiners to duly consider competent lay evidence of record, and to reserve the Board's right to determine credibility after all the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (citing Layno, 6 Vet. App. at 469); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the VA's examiner's opinion, which relied on the absence of contemporaneous medical evidence, 'failed to consider whether the lay statements presented sufficient evidence of the etiology of [the Veteran's] disability such that his claim of service connection could be proven '); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (holding that the VA examiner's opinion was inadequate where the examiner impermissibly ignored the appellant's lay assertions that he had sustained a back injury during service). Having thus determined that the prior VA examiners discounted key evidence of in-service injury and post-service continuity of symptomatology, the Board finds that their reports and addendum opinions were inadequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In contrast, the October 2012 VHA examiner expressly acknowledged, and did not dispute, the Veteran's account of in-service combat injuries. Nor did that examiner question the Veteran's assertions of a continuity of hand, finger, and left elbow symptomatology. Moreover, by referencing the prior VA examination findings as well as the Veteran's own statements, the VHA examiner demonstrated a familiarity with the pertinent facts of the case. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (holding that among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). Indeed, the Board considers it significant that the VHA examiner's report constitutes the most recent evidence of record and, thus, presumably took into account the relevant contents of the Veteran's claims file, which had been forwarded to that examiner in its entirety. See Marsh v. Nicholson, 19 Vet. App. 381 (2005) (noting that there is a presumption of regularity that VA and other government officials perform their duties correctly, fairly, in good faith, and in accordance with law and governing regulations); see also Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed. Cir. 2009) (applying the presumption of regularity to the competence of VA examiners). Such a thorough review of the evidence adds to the probative value of the VHA examiner's report, relative to the other medical opinions of record. Turning to the second and third criteria for weighing medical opinion evidence set forth in Nieves-Rodriguez , supra, the Board observes that the May 2008 VA examination report was wholly speculative regarding the etiology of the Veteran's bilateral hand and finger and left elbow disorders and, thus, is of minimal value in connection with his appeal. See Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Similarly, the December 2010 VA examination did not yield any etiological findings and, thus, is also lacking in probative weight. In contrast, the January 2011 VA examination report and the September 2009 and April 2011 addendum opinions were definitively negative with respect to any nexus between the Veteran's in-service injuries and current upper extremity disabilities. However, as noted above, the authors of that VA examination report and those addendum opinions declined to adequately weigh the lay assertions of the Veteran, and those of his son, with respect to in-service incurrence and continuity of symptomatology. As such, the rationales underlying the report and addendum opinions cannot be considered factually accurate, fully articulated, and sound. See Nieves-Rodriguez, 22 Vet App at 305. This further undercuts the overall evidentiary weight of that medical opinion evidence. Conversely, by rendering a definitively negative opinion and fully accounting for the pertinent medical and lay evidence, the VHA examiner solidified his report's status as the most probative medical opinion of record. Id. In this regard, the Board acknowledges that, while conclusively negating any link between the Veteran's cold weather exposure and current disabilities, the examiner's report appeared to leave open the possibility that those disabilities may have been causally related to a blunt traumatic injury, such as the Veteran incurred by falling into foxholes during combat. Nevertheless, the VHA examiner expressly noted that such a positive nexus could only be conceded if the Veteran provided greater detail about that in-service injury. This he has not done. Wood, supra. Accordingly, the Board finds that, on the basis of the current record, the VHA's examiner's report may be regarded as wholly negative with respect to a link between any of the Veteran's reported in-service injuries and his current hand, finger, and elbow complaints. Accordingly, in light of the October 2012 VHA examiner's report, which the Board finds highly probative, the preponderance of the evidence does not support a nexus between the Veteran's active service and the disabilities at issue in this appeal. Moreover, the Board considers it significant that reports of the prior VA examining clinicians, while less probative than that of the VHA expert examiner, do not expressly contradict that examiner's findings. Indeed, there are no medical opinions of record that denote a positive relationship between the Veteran's in-service combat injuries and his bilateral hand and finger osteoarthritis or his left elbow arthritis. The Board recognizes that the Veteran himself is of the opinion that such a positive relationship exists. However, while competent to attest to a history of in-service and post-service upper extremity symptoms, which are capable of lay observation, he has not shown that he has the expertise to comment on complicated medical issues, such as the nature and etiology of his current bilateral hand and finger osteoarthritis and left elbow arthritis. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). That is particularly significant where, as here, such conditions were not diagnosed until several decades after his discharge from the military. The inherent complexity of those current conditions makes it difficult to determine whether such disabilities are related to his active service. Moreover, whether the symptoms the Veteran reportedly experienced in service or following service are in any way related to his current disabilities is a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the Veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Accordingly, the Board finds that the etiology of the Veteran's bilateral hand and finger osteoarthritis and left elbow arthritis can only be resolved by a clinical expert, such as the October 2012 VHA examiner. That examiner's specialized training as a hand surgeon adds to the probative weight of his opinions, relative to the unvarnished views of the Veteran. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997). (in determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data). Indeed, the Board considers it significant that, while the Veteran clearly disagrees with the VHA examiner's negative nexus findings, he has not alleged that this specialist was unqualified to make such findings. Nor has he submitted any evidence refuting those findings or showing, in the alternative, that he himself is qualified to ascribe his currently diagnosed upper extremity disorders to injuries incurred during the Battle of the Bulge or any other aspect of World War II-era service. Next, the Board recognizes that, under current VA law, the nexus requirement may be satisfied through a showing of continuity of symptomatology, which may be established under certain circumstances through lay evidence. 38 C.F.R. § 3.303(b); Barr v. Nicholson, 21 Vet. App. 303 (2007). However, in this case, while the Veteran now professes to have experienced continuous hand, finger, and left elbow symptoms since service, the credibility of his current assertions is called into question by his earlier contradictory statements. As noted above, the Veteran expressly told the May 2008 and January 2011 VA examiners that, while he had experienced intermittent upper extremity symptoms since service, such symptoms had not become continuous or problematic until the mid-1980s. The Board finds those earlier statements, which were rendered in the course of VA medical examinations, to be more probative than the Veteran's subsequent written argument and testimony, which were presented solely in the pursuit of VA benefits following the perfection of his appeal. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made for the purposes of medical treatment may be afforded greater probative value because there is a strong motive to tell the truth in order to receive proper care); see also Caluza, 7 Vet. App. at 511 (a witness's credibility may be impeached by a showing of interest, bias, or inconsistent statements); Coburn v. Nicholson, 19 Vet. App. 427, 432 (2006) (Board may reject such statements of the Veteran if rebutted by the overall weight of the evidence). Moreover, the Board observes that the Veteran, by his own admission, did not complain of or seek treatment for hand, finger, and elbow disabilities for several decades following his discharge from service. The lengthy gap between his separation and the first manifestation of his current disabilities, while not a sufficient stand-alone basis for denying his claims for service connection, nevertheless weighs against those claims. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (ruling that a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred during the active military service and resulted in a chronic or persistent disorder). In light of the foregoing, the Board finds that, while the Veteran's reports of in-service upper extremity injuries are consistent with the terms of his combat service and are therefore deemed credible, the probative evidence of record weighs against the finding of a nexus between those in-service injuries and any current hand, finger, or elbow disorders. Thus, while cognizant that such disabilities need not manifest in service in order to establish service connection under current VA law, the Board finds that, given the particular evidence presented in this case, service connection is not warranted on a direct basis. Further, as there is no competent evidence indicating that the Veteran suffered from arthritis of the hands, fingers, or left elbow within one year following discharge from service, service connection on a presumptive basis is also not warranted. See 38 C.F.R. §§ 3.307, 3.309. Nor is service connection warranted on a secondary basis. In this regard, the Board is mindful of the Veteran's assertions that his bilateral hand and finger osteoarthritis and left elbow arthritis disorders are predicated on the same in-service cold weather injuries that gave rise to lower extremity disorders for which service connection was previously established. Notwithstanding that reported shared etiology, however, the Veteran has not alleged, and the record does not otherwise show, that his upper extremity disabilities were in any way caused or aggravated by those service-connected lower extremity cold weather residuals. Accordingly, the Board finds that the requirements for secondary service connection have not been met in this case. See 38 C.F.R. § 3.310. In sum, the Board is unable to grant service connection for bilateral hand and finger osteoarthritis or left elbow arthritis under any of the theories presented by the Veteran or otherwise suggested by the record. In reaching this conclusion, the Board remains sympathetic to the Veteran and does in any way wish to diminish his combat-decorated World War II-era service. Nevertheless, the preponderance of the evidence weighs against both of his service connection claims. Therefore, while the Board has considered the benefit of the doubt rule, that rule is inapplicable and the Veteran's claims must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Service connection for bilateral hand and finger osteoarthritis is denied. Service connection for left elbow arthritis is denied. ____________________________________________ S. C. Krembs Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs