Citation Nr: 1307646 Decision Date: 03/07/13 Archive Date: 03/11/13 DOCKET NO. 05-18 071 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Entitlement to service connection for ulnar neuropathy with residual nerve deficit and pain, left elbow. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from July 1977 to July 1981, October 1987 to February 1988, and January 2002 to December 2002. The Veteran also served in a Reserve capacity with a documented period of active duty for training (ACDUTRA) in July 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York, which denied entitlement to the benefit currently sought on appeal. The Veteran's claim was remanded by the Board for additional development in December 2008 and February 2011. Thereafter, in May 2012 the Board referred the case to the Veterans Health Administration (VHA) for an expert opinion concerning the Veteran's left ulnar neuropathy. See 38 U.S.C.A. § 7109 (West 2002); 38 C.F.R. § 20.901(d) (2012). The resulting June 2012 opinion and October 2012 addendum have been included in the claims file for review. The Veteran along with his accredited representative were notified of the VHA opinion in accordance with Thurber v. Brown, 5 Vet. App. 119 (1993). The record reflects that after the final supplemental statement of the case (SSOC) the Veteran submitted additional relevant evidence to the Board. No subsequent SSOC was issued, but this is not necessary because the evidence was accompanied by a waiver of initial review by the agency of original jurisdiction in accordance with 38 C.F.R. § 20.1304 (2012). The Board has not only reviewed the Veteran's physical claims file, but also his Virtual VA electronic claims file to ensure a total review of the evidence. FINDING OF FACT Clear and unmistakable evidence demonstrates that the Veteran's left ulnar neuropathy preexisted his final period of active duty service, and clear and unmistakable evidence demonstrates that the left ulnar neuropathy was not aggravated by service, as any increase in disability was due to the natural progression of the disease. CONCLUSION OF LAW The criteria for establishing entitlement to service connection for ulnar neuropathy with residual nerve deficit and pain, left elbow, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1111, 1131, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. 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). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VCAA letters dated in June 2004 and March 2011 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claim. The letters informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The March 2011 letter explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Furthermore, even if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced Veteran Service Organization and has submitted argument in support of his claim. These arguments have referenced the applicable law and regulations necessary for a grant of entitlement to service connection. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claim and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file, including records sought as directed in previous remand. The Board acknowledges that despite previous remand directives, the Veteran's duty status at the time of a May 1989 fall that resulted in a fracture of the left shoulder has not been confirmed. As will be discussed in greater detail below, however, there is no medical or lay evidence to indicate that the May 1989 incident caused or otherwise contributed to the Veteran's current left ulnar neuropathy. As such, the Board concludes that additional remand in an attempt to confirm the Veteran's duty status for this time period would serve no useful purpose. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time otherwise referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). In that regard, the Veteran was afforded VA examinations in July 2004, July 2009, and November 2009. In addition, the RO sought an additional medical opinion, which was rendered in October 2011. Finally, the Board sought a medical opinion through the Veterans Health Administration (VHA). The resulting June 2012 VHA medical opinion and October 2012 addendum are of record. The Board notes that the previous remands found portions of the VA examinations to be inadequate; however, the Board finds the October 2011 VA opinion combined with the VHA opinion report and addendum to be thorough and complete. The opinions expressed were based on the Veteran's reported history and review of the claims file. The opinions were supported by a complete rationale. Based on the opinions of record and the fact there is no rule as to how current an examination must be, the Board concludes the opinions in this case are adequate upon which to base a decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007) (finding that an adequate opinion is one that is based upon consideration of the Veteran's prior medical history and examinations, describes the disability in sufficient detail, and includes a conclusion supported by an analysis that the Board can consider and weigh against contrary opinions). Based on the association of VA treatment records (to the extent available), the March 2011 VA notice letter, the association of records from the U.S. Postal Service, the multiple opinions of record, and subsequent readjudication of the claim, the Board finds that there has been substantial compliance with its December 2008 and February 2011 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in line of duty. 38 U.S.C.A. § 101(21) and (24) (West 2002 & Supp. 2012); 38 C.F.R. § 3.6(a) (2012). Active military, naval, or air service also includes any period of inactive duty training (INACDUTRA) duty in which the individual concerned was disabled from injury incurred in the line of duty. Id. Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ACDUTRA or from injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1131 (West 2002 & Supp. 2012). In addition, service connection may be granted for residuals of an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during INACDUTRA. 38 C.F.R. § 3.6(a). ACDUTRA includes full time duty performed by members of the National Guard of any state or the reservists. 38 C.F.R. § 3.6(c). INACDUTRA includes duty other than full time duty performed by a member of the Reserves or the National Guard of any state. 38 C.F.R. § 3.6(d). In this case, the Board notes that the Veteran had many years of Army Reserve service. As was alluded to above, there is some confusion as to whether the Veteran was serving a period of INACDUTRA or ACDUTRA in May 1989 when he incurred a fracture of the left femoral neck, also termed a left shoulder fracture. The above notwithstanding, the Board concludes that it is immaterial whether the Veteran was serving on INACDUTRA or ACDUTRA at the time of the May 1989 accident, as there is no medical evidence or lay contention that the May 1989 fracture of the left humeral head caused or otherwise contributed to the Veteran's current ulnar neuropathy. Indeed, there is significant medical evidence to the contrary, including the October 2012 VHA clarifying addendum opinion. The Veteran also has conceded that the sole problem incurred in May 1989 was a left shoulder fracture and does not contend that it caused any of his current neurological problems of the left upper extremity. As such, the Board will give no further consideration to granting entitlement to service connection based on any periods of ACDUTRA or INACDUTRA prior to the Veteran's third period of active service from January 2002 to December 2002. With respect to this period of service, the Board notes that an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In this case, the Veteran claims that he permanently aggravated a preexisting left ulnar neuropathy condition as the result of a January 2002 accident in which his left elbow was struck by an opening door, which subsequently required corrective surgery in April 2002. The evidence of record does not show any chronic neurological or orthopedic impairment affecting the left upper extremity prior to May 1989. Then, as discussed above, the Veteran suffered a fall on the left shoulder resulting in a fracture of the neck of the humerus in May 1989. In November 1989, the Veteran denied a history of a painful or "trick" elbow. Subsequently, in July 1998, while the Veteran was employed by the U.S. Postal Service and working in the post office, the Veteran again suffered a fall, resulting in a fracture through the left olecranon process. The Veteran underwent an open reduction internal fixation (ORIF) in July 1998. In May 1999, the Veteran reported continued mild discomfort to his private treatment provider. That same month, the Veteran sought initial treatment with VA. At that time, he reported intermittent left elbow pain. In a June 1999 Report of Medical History, the Veteran also reported left elbow pain. In September 1999, the Veteran reported, "an increase in severity of numbness into his small and ring fingers over the past several months or so that he has not described to me before." The treating physician ordered an EMG to rule out cubital tunnel syndrome that "would be as a result of his olecranon fracture and casually related to." The resulting EMG showed no physiologic evidence of ulnar neuropathy on the left, but the diagnosis was status post removal of hardware from elbow, mild cubital tunnel syndrome. In December 1999, the Veteran reported a slow increase in ulnar nerve symptomatology since the 1998 surgery. In March 2000, the Veteran had a positive Tinel's sign in his left cubital tunnel with significant loss of sensation. An April 2000 EMG study was normal, with no electrodiagnostic evidence of left ulnar neuropathy. An August 2001 VA treatment record noted ongoing left upper extremity residual neuropathy following surgery for a traumatic accident to the left elbow. Then, during active duty service in January 2002, the Veteran was struck in the elbow by a door being opened and experienced pain in the elbow and numbness in the fingers. In March 2002, the Veteran reported a history of left elbow fracture with pinning removed about one year later. "Since that time he has had elbow pain with numbness in the [ring finger] and [small finger]. The pain is described as constant dull with increase to sharp with activity." The Veteran did not describe a worsening of symptoms following the January 2002 door accident. A March 2002 EMG showed evidence for left ulnar sensorimotor neuropathy at the left wrist, but no evidence of ulnar neuropathy across the left elbow (cubital tunnel). The Veteran then underwent surgery in April 2002 for decompression of the ulnar nerve and cubital tunnel. A July 2003 private treatment record noted some remaining numbness in the left hand from left ulnar damage following a fall at the post office with resulting fracture in 1998. In support of his claim, the Veteran submitted a July 2003 statement from a treating physician that noted, "I have stated clearly to him I think that although the olecranon fracture may have contributed to his ongoing cubital tunnel syndrome the massive surgical intervention that took place in the Service and the resulting poor outcome from this certainly may have played somewhat of a role." The Veteran was afforded a VA general medical examination in July 2004. The examiner noted review of the claims file. The Veteran reported his 1998 left elbow fracture and stated that he was doing relatively well until the in-service accident with the door striking his elbow that resulted in the onset of increasing numbness in the fourth and fifth fingers and pain in the left elbow. There was current numbness of the median side of the left elbow, hyperesthesia, increased sensitivity of the olecranon area, numbness of the fourth and fifth fingers, and intermittent twitching of the entire left forearm. The assessment was ulnar neuropathy with two surgeries on the ulnar nerve while in the military with residual neurologic deficit in the ulnar distribution on the left. The Veteran was afforded another VA examination in July 2009. The examiner noted review of the claims file. The examiner noted the March 1999 treatment record that did not include reports of neuropathy, the in-service injury involving the door, and the multiple in-service operations for neurological problems in 2002. On examination, peripheral neuropathy was limited to the distribution of the left ulnar nerve. The examiner diagnosed status post fracture of the right elbow, unrelated to military service and right ulna neuropathy, status post service-related injury, resulting in residual paresthesia and dysesthesia in the ulna distribution as described. The examiner opined that the injury of the right elbow sustained in military service resulted in no damage to the left elbow, but did result in a left ulnar neuropathy that had been stable over the past five years without expectation of further improvement. In November 2009, the Veteran underwent another VA examination. The examiner noted that the claims file had been reviewed. The examiner stated that the Veteran had fractured his right elbow in 1998, injured his left elbow in February 2002 in a door accident, had an EMG that showed entrapment at the left elbow and wrist, in April 2002 underwent an ulna pranslocation at the left elbow and ulna release at the left wrist, and experienced ongoing left upper extremity symptomatology. The examiner concluded that it was not likely that the 2002 in-service door injury altered the preexisting left arm symptomatology. The rationale was that the involved area would not likely have received the blunt trauma as it was on the medial aspect of the arm and not likely exposed and that electrodiagnostic evidence of entrapment would not have taken place in such a brief period between injury and surgery. That said, the examiner also noted that the Veteran underwent surgery in service with the expectation that it would relieve his of the neuropathic symptoms, which the surgery did not. As such, the examiner concluded that the Veteran's ulnar neuropathy arose from the in-service surgery to the left upper extremity. Pursuant to the Board's February 2011 remand instructions, a VA medical opinion was obtained in October 2011. The reviewer noted that there was clear evidence that the ulnar neuropathy began several months before October 1999, based on the private treatment records discussing the onset of symptomatology during that time period. The cause of the ulnar neuropathy was the 1998 left elbow fracture and resulting scarring in the area, as documented in the December 1999 private treatment note discussed above. As to whether the ulnar neuropathy worsened between January and December 2002, the reviewer noted that the March 2002 EMG study showed some evidence of compression of the wrist, but did not confirm significant damage to the elbow. Thus, there was no physiologic evidence of ulnar neuropathy on the left, which was confirmed by other medical professionals. The subjective symptoms of hypersensitivity to touch and vibration may have worsened after surgery, but was difficult to confirm. Thus, ulnar nerve function did not deteriorate as a result of the in-service 2002 surgery, although the subjective symptoms of ulnar neuropathy more likely than not did worsen after surgery. As to whether such post-operative difficulties were unusual, the reviewer stated that this question was probably best answered by a surgeon experienced in the field. That said, the reviewer noted that there was no major injury to the nerve, the Veteran did not develop any new motor or sensory deficits, and the surgery's goal of preventing progression of the neuropathy was achieved. The surgery achieved preservation, if not restoration, of nerve function. As noted above, the Board obtained a VHA medical opinion that was provided in June 2012, with an addendum opinion provided in October 2012. The addendum opinion clarified that a transcription error had occurred in the June 2012 opinion report. The reviewing physician concluded that the onset of the ulnar neuropathy was following the July 1998 left elbow fracture, with noted neuropathy symptoms in October 1999 and December 1999. The reviewer opined that it was unlikely that the May 1989 fracture of the left humerus neck caused the left ulnar neuropathy given the anatomical disparity between the location of the source of symptoms for the ulnar neuropathy and the location of the fracture in the shoulder. The reviewer concluded that the July 1998 left elbow fracture and subsequent surgical fixation at least as likely as not contributed to much of the Veteran's current ulnar nerve symptoms. Ulnar neuropathy symptoms were noted to be mild and intermittent at the time of the surgery and became more prominent over the following year. It was less likely than not that the January 2002 in-service door injury caused any further worsening of the symptoms, as the February 2002 workup by the orthopedic surgeons prior to the April 2002 surgery failed to mention the January 2002 traumatic injury. In addition, the reviewer did not believe that the April 2002 ulnar nerve and cubital tunnel surgical procedure aggravated or contributed to the Veteran's ulnar neuropathy because the surgery was accomplished without apparent complication and likely prevented additional symptoms from developing. It was just as likely that the Veteran's symptoms would have developed or become worse had he not undergone the April 2002 surgery. There was no evidence to suggest that the surgery aggravated the Veteran's symptoms. The examiner concluded that between January 2002 and December 2002 no event contributed to any worsening of the Veteran's ulnar neuropathy. Any evidence to suggest that the January 2002 door incident exacerbated the ulnar neuropathy symptoms was weak, as such a blow would not likely strike the ulnar nerve by the elbow and it was difficult to understand the mechanism by which such accident could aggravate ulnar neuropathy. In addition, the January 2002 incident was not mentioned the February 2002 clinician's evaluation of ulnar neuropathy. The April 2002 surgery was carried out appropriately and any subsequent increase in symptoms was more likely the natural history of progressively increasing ulnar nerve symptoms than due to any result of the surgery. Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002). In order to rebut the presumption of soundness at service entry, there must be clear and unmistakable evidence showing that the disorder preexisted service and there must be clear and unmistakable evidence that the disorder was not aggravated by service. The Veteran is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOPGPREC 3-2003 (July 16, 2003); Jordan v. Principi, 17 Vet. App. 261 (2003); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). However, where a preexisting disease or injury is noted on the entrance examination, section 1153 of the statute provides that "[a] preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease." 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306(a) (2012). For Veterans who served during a period of war or after December 31, 1946, clear and unmistakable evidence is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service, and clear and unmistakable evidence includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition itself, as contrasted with mere symptoms, has worsened. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Initially, the Board notes that a medical examination is not of record at the time of the Veteran's entrance into active service in January 2002. As such, the Veteran will be presumed to have entered service in sound condition with respect to left ulnar neuropathy. 38 U.S.C.A. §§ 1111 (West 2002); see also Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). As noted, however, the presumption can be rebutted by clear and unmistakable evidence. In this case, the evidence of record clearly establishes the Veteran's left ulnar neuropathy preexisted his period of active service beginning in January 2002. As noted above, myriad private, military, and VA medical records document the Veteran's left ulnar neuropathy that began following his July 1998 left elbow fracture and symptoms of which were first documented in October 1999. The lay and medical evidence of record is unanimous that the left ulnar neuropathy began after the Veteran's first two periods of active service and documented ACDUTRA service and prior to the Veteran's military service from January 2002 to December 2002. In light of the foregoing, the Board finds that there is clear and unmistakable evidence of record that the Veteran's left ulnar neuropathy preexisted service from January 2002 to December 2002. See Doran v. Brown, 6 Vet. App. 283, 286 (1994). The Board notes that the presumption of soundness on entrance cannot be overcome simply based on the representations of the Veteran of a vague past history during the entrance examination or thereafter. See Miller v. West, 11 Vet. App. 345, 348 (1998) (holding that a veteran's self-report that he had previously suffered from "depression or excessive worry" prior to service was insufficient to rebut the presumption of soundness as was found in 38 U.S.C.A § 1111); see also Crowe v. Brown, 7 Vet. App. 238, 246 (1995). In this case, however, as discussed above there is both probative clinical and lay evidence of the preexisting disorder. As set forth in VAOPGCPREC 3-2003, the Board must also determine if there is clear and unmistakable evidence that the disorder was not aggravated during service. In this case, the Board finds clear and unmistakable evidence establishing that the Veteran's left ulnar neuropathy was not aggravated by service. In this regard, the most credible in-service and post-service medical evidence of record clearly and unmistakably supports the conclusion that to the extent the Veteran's preexisting left ulnar neuropathy problems were aggravated by his military service that the increase in disability represented the natural progress of the disease. In that regard, the Board finds the opinions expressed in the October 2011 VA medical opinion of significant probative value. The reviewing medical professional considered the Veteran's contentions and the other evidence of record, but concluded that the ulnar neuropathy condition itself did not worsen as a result of the Veteran's January 2002 to December 2002 military service, to include the January 2002 door accident and April 2002 surgery. While the subjective symptoms of hypersensitivity to touch and vibration may have worsened, as discussed above, a worsening of symptoms without an increase in the underlying disability is insufficient. See Jenson, 4 Vet. App. at 306-07. The Board also finds the conclusions of the June 2012 VHA opinion and October 2012 addendum of significant probative value. The reviewing VA surgeon considered the Veteran's contentions, but concluded that any increase in left ulnar symptomatology was due to the natural progression of the disease and unrelated to the January 2002 door accident, the April 2002 surgery, or other incident of service. In each of these cases, a complete and thorough rationale is provided for the opinions rendered. The reviewers' conclusions are fully explained and consistent with the credible evidence of record. Moreover, to the extent that the above reports used the term "at least as likely as not" or "less likely than not" when opining as to whether the Veteran's current left ulnar neuropathy problems were aggravated by service, the Board looks to the comprehensive opinion reports, the detailed discussion of the Veteran's in-service and post-service medical history, and the thorough rationale contained throughout the opinions in concluding that the reviewers' opinions are unequivocal in their finding that the Veteran's left ulnar neuropathy problems were not aggravated by service, as such represented only an increase in symptomatology and not the underlying disorder or that any such increase in symptomatology was representative of the natural progression of the disease. See Emenaker v. Peake, 551 F.3d 1332, 1335 (Fed. Cir. 2008) (finding that the "least as likely as not" language was not fatal to the medical opinion as long as there was an adequate explanation of whether the opinion rises to the level of clear and unmistakable evidence despite the equivocal phrase). The reviewers' conclusions also are supported by the above noted treatment records that both immediately prior to and subsequent to the April 2002 surgery extensively discussed the Veteran's ongoing left ulnar neuropathy symptoms following the May 1998 left elbow fracture, but failed to mention any increase in symptoms following the January 2002 in-service door accident. Indeed, the March 2002 private treatment record, discussed above, specifically noted that the left ulnar neuropathy symptoms had been present and consistent since the removal of the pinning used to repair the May 1998 elbow fracture. By contrast, the Board finds the conclusions rendered in the July 2003 private physician's letter and the July 2004, July 2009, and November 2009 VA examination reports of no probative value. As noted above, these records (save for the November 2009 VA examination report) failed to consider or discuss the multiple diagnoses of left ulnar neuropathy prior to the Veteran's January 2002 to December 2002 period of active service. For example, the July 2009 VA examination report indicated that following the Veteran's 1998 left elbow fracture that following casting and physical therapy he "return[ed] to pre-level function." Clearly, this is an inaccurate statement of the facts given the extensive evidence of left ulnar neuropathy symptomatology documented from at least October 1999. The examiner, however, ignored these records and instead focused on a March 1999 private record wherein the Veteran denied neuropathy symptoms and then proceeded immediately to the April 2002 evidence of ulnar neuropathy. The July 2004 examiner failed to discuss any treatment for neuropathy prior to the Veteran's final period of active service, but in fairness these records had not been associated with the claims file at the time of the examination. Similarly, the July 2003 private physician's letter discussed only the Veteran's ulnar neuropathy symptoms beginning in service, without reference to the multiple years of ongoing symptomatology. While the November 2009 VA examiner noted treatment for and diagnosis of left ulnar neuropathy prior to the January 2002 door injury, the examination report inexplicably concluded that because the April 2002 surgery did not resolve the preexisting ulnar neuropathy symptoms that ulnar neuropathy arose from the in-service surgery. As discussed above (and as noted within the November 2009 examination report itself), it is clear that the ulnar neuropathy arose as a result of the May 1998 left elbow fracture. Accordingly, the Board considers the July 2003 private physician's letter and the July 2004, July 2009, and November 2009 VA examination reports to be based on an incorrect factual premise and, therefore, of no probative value here. See Reonal v. Brown, 5 Vet. App. 458 (1993); see also Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (holding that the Board may reject a medical opinion that is based on facts provided by the Veteran that have been found to be inaccurate or that are contradicted by other facts of record). Moreover, the mere manifestation of symptoms, such as decreased sensitivity in the left upper extremity or left elbow pain, does not demonstrate that the underlying left ulnar neuropathy disability underwent a permanent increase in severity in service. See generally Townsend v. Derwinski, 1 Vet. App. 408 (1991). The underlying disorder, as opposed to the symptoms, must be shown to have worsened in order to find aggravation. As discussed above, there is conflicting evidence of record as to whether the Veteran's subjective symptomatology in fact worsened during military service. Affording the Veteran the benefit of the doubt and presuming that there was an increase in left ulnar neuropathy symptomatology during service, the most probative medical evidence of record, to include the October 2011 VA medical opinion, clearly concludes that any increase in subjective symptomatology was not representative of an increase in severity of the underlying disability. Thus, the evidence of record supports the conclusion that a permanent aggravation of a preexisting left ulnar neuropathy disorder did not occur. See Jensen, 4 Vet. App. at 306-07; Green, 1 Vet. App. at 323; Hunt, 1 Vet. App. at 297. Indeed, the only probative evidence that the Veteran's left ulnar neuropathy was permanently aggravated by service is his own lay assertions. However, an increase in symptomatology during service is not inconsistent with the October 2011 VA reviewer's and the June 2012 VHA reviewer's findings that the underlying disability did not undergo a permanent increase in severity and, to the extent that such an increase in disability occurred during service, it represented the natural progression of the condition. The Veteran certainly is competent to report worsening symptomatology, such as increased loss of sensation or elbow pain, and a lay person also is competent to provide opinions on some medical issues. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); see also Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). That said, the Board finds that opining as to a worsening of a complex medical condition like ulnar neuropathy falls outside the realm of common knowledge of a lay person and, as such, the Veteran's opinions in that regard are not competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Therefore, in summary, the Board finds that the credible and probative evidence of record clearly and unmistakably shows that the Veteran's left ulnar neuropathy preexisted service and was not aggravated therein beyond the natural progression of the disease. For this reason, the Board finds that service connection for left ulnar neuropathy with residual nerve deficit and pain, left elbow, is denied. ORDER Entitlement to service connection for left ulnar neuropathy with residual nerve deficit and pain, left elbow, is denied. ____________________________________________ A. C. MACKENZIE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs