Citation Nr: 1308094 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 10-47 142A ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for residuals of a cerebral vascular accident, to include as a result of exposure to ionizing radiation. 2. Entitlement to service connection for right arm nerve disability. 3. Entitlement to service connection for left arm nerve disability. ATTORNEY FOR THE BOARD Russell P. Veldenz, Counsel INTRODUCTION The Veteran served on active duty from March 1986 to March 1990. The Veteran had requested a hearing, but the Veteran withdrew that request in February 2010 as documented in writing by the RO. In June 2012, the Board remanded the case to the RO for additional development. As the requested development has been completed, no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). In a rating decision in November 2012, the RO denied a claim for service connection for hypertension. As the Veteran has not initiated an appeal of the claim, the claim has not been developed for appellate review by the Board. The Veteran does have the remainder of the one-year period from November 7, 2012, to file a notice of disagreement to initiate an appeal of the claim. This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in June 2008 of a Department of Veterans Affairs (VA) Regional Office (RO) in Portland Oregon. The RO in Salt Lake City currently has jurisdiction of the file. FINDINGS OF FACT 1. The Veteran was not diagnosed or treated for a cerebral vascular accident or cerebral vascular accident residuals or symptoms in service, including hypertension, and residuals of a cerebral vascular accident was not manifested to a compensable degree within one year from the date of separation from service; and is unrelated to an injury or disease or event in service, including exposure to ionizing radiation. 2. The Veteran was not diagnosed or treated for right arm nerve disability or symptoms of a right arm nerve disability in service and a right arm nerve disability was not manifested to a compensable degree within one year from the date of separation from service; and is unrelated to an injury or disease or event in service. 3. The Veteran suffered abrasions of the right arm in service but did not experience an acute injury or chronic symptoms of a right arm nerve disability during service. 4. The Veteran does not have a diagnosed neurological disability of the right arm. 5. Symptoms claimed as such as pain, numbness and tingling, and a weakened grip have not been related to any diagnosed disability of the right arm and the right arm has been found to be essentially normal upon examination. 6. The Veteran was not diagnosed or treated for left arm nerve disability or left arm nerve disability symptoms in service and a left arm nerve disability was not manifested to a compensable degree within one year from the date of separation from service; and is unrelated to an injury or disease or event in service. CONCLUSION OF LAW 1. Residuals of a cerebral vascular accident are not related to service including exposure to ionizing radiation, and may not be presumed to be related to service. 38 U.S.C.A. §§ 1110, 1112, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. The criteria for service connection for a right arm nerve disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 3. The criteria for service connection for a left arm nerve disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of 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. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The RO provided pre- adjudication VCAA notice by letters, dated in April 2007 and July 2008. The notice included the type of evidence needed to substantiate the underlying claims of 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. 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) (38 C.F.R. § 3.159 notice); and of Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim). 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 the claim. The RO has obtained service treatment records, VA records, records from the Social Security Administration, and afforded the Veteran VA examinations in October 2010 and June 2011. The reports of the VA examinations included a review of the Veteran's medical history, including his service treatment records, an interview and an examination of the Veteran, sufficient findings to rate any disability and offered opinions whether any current disability is related to service. Therefore, the Board concludes that the VA examinations are adequate. 38 C.F.R. § 4.2; 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). As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist Facts and Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110, 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 showing inception or aggravation during service. 38 C.F.R. § 3.303(a). The showing of a chronic disease, such as brain hemorrhage or hypertension, in service requires 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). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for certain disabilities such as brain hemorrhage, brain thrombosis, or organic diseases of the nervous system, if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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). 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). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Competent medical evidence means 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. 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). Service Connection for Residuals of a Cerebral Vascular Accident VA records establish that in February 2007, the Veteran suffered a cerebral vascular accident, or more specifically, referred to in the records as a right lateral medullary infarction, or Wallenberg's Syndrome. The Veteran had already been diagnosed with hypertension and he asserts that hypertension was the cause of his cerebral vascular accident. Further he states that in service he served aboard the USS Los Angeles and was exposed to ionizing radiation as part of his duties and that his bunk was located near missiles with nuclear material. He also states that his hypertension resulted from the ionizing radiation exposure and he had high blood pressure in service. The entrance examination in February 1986 did not include a history of any cardiovascular, renal, or neurological condition. The physical examination was normal and his blood pressure was 132/64. Thereafter, while in service, the Veteran was treated for kidney stones in February 1989. An intravenous pyleogram in March 1989 was normal. There was no treatment for any cardiovascular or neurological conditions. His blood pressure readings, when taken, were normal, ranging from 130/70 in January 1987 to 102/76 in May 1988. The service treatment records confirm that the Veteran served aboard the USS Los Angeles. The records contain recorded ionization radiation exposure for the Veteran from June 1986 to January 1990. The records indicate exposure readings are based upon his film badge readings. He received a total life dose of .116 rem with a permissible lifetime exposure of 95.00. At the separation examination in January 1990, the Veteran's blood pressure was 130/82 and his physical examination was normal. The Veteran stated his health was good and specifically gave a negative history of high blood pressure or any neurological symptoms or problems. After service, the next medical evaluation or treatment of the Veteran starts with VAMC treatment in August 2006. In early February 2007, it was noted the Veteran had hypertension since 2005. Shortly thereafter, the Veteran suffered his cerebral vascular accident. In April 2007, a VA physician stated he did not know if ionization radiation caused hypertension. In February 2008, the Veteran submitted a statement to VA that one of his VA primary physicians told him off the record that ionizing radiation as likely may have caused the hypertension, which resulted in the cerebral vascular accident. He also stated that the film badges were often thrown away and corpsmen wrote down different numbers to avoid trouble. He also submitted various articles which appear to indicate that hypertension may result from high radiation exposure. In March 2008, the NPRC stated it had no DD Form 1141 or records of exposure of ionizing radiation regarding the Veteran. The Board notes that VA already had the DD Form 1141 as it is part of the Veteran's service treatment records. In September 2010, a VA physician wrote it was unlikely the Veteran developed hypertension due to ionizing radiation exposure given his particular exposure. Hypertension resulted only from Hiroshima survivors or those who assisted in the open air testing of nuclear devices. It was theoretically possible that the ionizing radiation exposure caused the Veteran's hypertension. In October 2010, the Veteran received a VA examination where the Veteran stated he was diagnosed with hypertension two years before separation and was placed on medication. The Veteran also stated that no one wore the ionizing radiation badges because if it got lost, the serviceman would end up scrubbing decks forever. The examiner noted the service treatment records do not contain a history or treatment of hypertension, including medication. There also was no evidence of kidney dysfunction with normal laboratory test results and the IVP was normal. The examiner noted that the cerebral vascular accident appears to have been an ischemic stroke and that it was as likely as not hypertension was at least a partial cause of the cerebral vascular accident. As to whether hypertension resulted from the Veteran's ionizing radiation exposure, the VA examiner referred to a review of the literature which stated that if the radiation is directed specifically at the kidney level as it occurs in bone marrow transplant patients, radiation nephropathy can occur and that includes resulting hypertension. The doses that the Veteran received, however, do not fit the picture of exposure, nor was the radiation directed towards the kidney. Further, evidence in service showed normal kidney function in service, that is, the kidney stones did not affect or indicate impairment of renal function or nephropathy. Therefore, the examiner concluded the Veteran's hypertension was not caused by or aggravated by ionizing radiation. Initially, the Board recognizes that VA provides a presumption of service connection for certain disabilities to Veterans who participated in a radiation risk activity. 38 C.F.R. § 3.309 (d). Residuals of a cerebral vascular accident or hypertension are not one of the disabilities included. Furthermore, § 3.309 also defines radiation risk activity and the Veteran does not meet the requirements of a radiation risk activity Veteran as defined by § 3.309. Therefore, the presumption of § 3.309 (d) does not apply in this case. The Board recognizes that the Veteran believes his service, specifically exposure to ionizing radiation resulted in hypertension which in turn caused his cerebral vascular accident. The Veteran is competent to testify to the events in service and after, including when he developed blood pressure symptoms. 38 C.F.R. § 3.159. He is also to testify as to events concerning his ionizing radiation including his performance of duties aboard the USS Los Angeles. The question still remains as to whether the Veteran's residuals of a cerebral vascular accident are due to service. Service connection may be established by either continuity of symptomatology after service under 38 C.F.R. § 3.303(b) or by initial diagnosis of the medical condition after service under 38 C.F.R. § 3.303(d). The Federal Circuit recently held that continuity of symptomatology under 3.303(b) applies only to chronic diseases listed in 3.309. Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Hypertension and brain hemorrhage are both listed as chronic diseases. As noted, as a lay person, the Veteran is competent to describe symptoms, which he is able to perceive through the use of his senses. 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). Further, the Veteran's statements and testimony are admissible and are to be considered as evidence of continuity. Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept in determining whether lay evidence may be considered, in other words, whether the evidence is admissible). The Board thus finds that the Veteran is competent to describe his symptoms in service and thereafter. While there is evidence of continuity of symptomatology, it does not necessarily follow that there is a relationship between a current diagnosis, for example, hypertension, and the continuity of symptomatology as stated by the Veteran. Medical evidence is required to demonstrate such a diagnosis and a relationship to service unless such the diagnosis and the relationship to service is one to which a lay person's observation is competent. See Savage v. Gober, 10 Vet. App. 488, 497 (1997) (medical evidence is required to demonstrate continuity of symptomatology and any present disability unless such a relationship is one to which a lay person's observation is competent). Although the Veteran is competent to describe hypertension symptoms, or the residuals of his cerebral vascular accident, unless hypertension or a cerebral vascular accident are conditions under case law that has been found to be capable of lay observation, the determination as to the presence or diagnosis of such a disability therefore is medical in nature and competent medical evidence is required to substantiate the claim. Savage, 10 Vet. App. at 498 (On the question of whether there is a chronic condition since service, the evidence must be medical unless it relates to a condition as to which, under case law, lay observation is competent); Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Hypertension and cerebral vascular accidents are not conditions under case law that have been found to be capable of lay observation. See Jandreau, 492 F.3d at 1377 (explaining in a footnote, sometimes a layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); see also Barr, 21 Vet. App at 309 (varicose veins were subject to non-expert diagnosis due to the readily observable defining characteristics of the condition). Furthermore, the diagnosis of hypertension and cerebral vascular accidents cannot be made by the Veteran as a lay person based on mere personal observation, that is, perceived by visual observation or by any other of the senses. As demonstrated by this case, the diagnosis depends upon interpretation of symptoms, and clinical and diagnostic tests, such as X-rays and laboratory tests, which requires medical knowledge. No factual foundation has been established that the Veteran is otherwise qualified through specialized education, training, or experience to offer a medical diagnosis. Therefore, the Veteran's assertion or opinion that he has hypertension, or more generally, the onset of symptoms that lead to the cerebral vascular accident started in service is not competent evidence and to this extent his statements and testimony are not admissible as evidence of the presence or diagnosis of hypertension or the onset of the condition that lead to his cerebral vascular accident since service based on continuity or as an opinion based on causation. While the Veteran cannot offer his opinion as to the onset and cause for hypertension or the cerebral vascular accident, the Veteran is competent to offer evidence as to his symptoms or events that happened while he was in service. The Board finds the Veteran is credible as to his current symptoms, but the Board does not find credible his statements as to when he was diagnosed with hypertension and that his ionizing radiation exposure records are inaccurate. Turning first to hypertension, the Veteran asserts he was diagnosed with hypertension and treated in service, including medication. The Board notes, however, that the service treatment records do not show a diagnosis of hypertension or treatment, including prescriptions, and all readings of blood pressure in service were normal. The medical community has defined hypertension as high arterial blood pressure with a minimum threshold of 140 mm for systolic blood pressure and 90 mm for diastolic blood pressure. See Duenas v. Principi, 18 Vet. App. 512, 520 (2004) (citing Dorland's Illustrated Medical Dictionary, 801 (28th ed. 1994). Moreover, at the Veteran's separation examination, the Veteran denied experiencing high blood pressure, cardiovascular, renal, or heart problems; his examination showed a normal clinical evaluation of the heart, renal, and vascular system, and no high blood pressure readings were noted. The service treatment records are probatively significant and given a lot of weight and credibility because they were prepared at a time contemporaneous to the alleged incident in question. See, e.g., Struck v. Brown, 9 Vet. App. 145, 155-56 (1996). Finally, shortly before his cerebral vascular accident, the Veteran told his medical providers that his hypertension was diagnosed in 2005. The Board recognizes lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim). Instead, in determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). Here, the Board finds the Veteran's evidence in conflict with positive medical evidence in service that he did not have hypertension and medical evidence before the cerebral vascular accident that he was diagnosed with hypertension in 2005. The Board therefore finds the Veteran's evidence that he was diagnosed with hypertension in service to be less credible then the medical records and the medical records are given more probative weight. As to the Veteran's contention that his dose exposure records are not accurate, the Board notes he has given conflicting evidence on this point. On one occasion, he states the corpsmen wrote down numbers different then what the badge reported. On another occasion, he stated no one ever wore the badges. The United States Court of Appeals for Veterans Claims (Court) has ruled that there is a "presumption of regularity" under which it is presumed that government officials have properly discharged their official duties. Clear evidence to the contrary is required to rebut the presumption of regularity. Ashley v. Derwinski, 2 Vet. App. 307, 308 (1992), (citing United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15 (1926)). Other than his statements, the Veteran has presented no objective evidence, witnesses, or other evidence to rebut the presumption of regularity. The Board therefore finds that the dose records of exposure from service are accurate. The Veteran, as a lay person, is competent not only to identify a simple medical condition, but also a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As for the Veteran relating symptoms that later support a diagnosis by a medical professional, he stated that a VA physician told him off the record that his hypertension resulted from his service ionization exposure. The Board finds that this statement, standing alone, is too generalized to be assigned much probative weight as there is no indication the physician accounted for all of the facts of this case. Further, VAMC physicians have not noted such a conclusion. One physician believed it fell outside his expertise. Another concluded that the Veteran would need much higher levels of exposure, but only conceded it was theoretically possible. The Board finds that this is an opinion that is couched in terms of possibility and has little weight. See Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (medical opinions which are speculative, general or inconclusive in nature cannot support a claim). In a similar manner, the Board notes that the Veteran has submitted several articles that do suggest there is a link between hypertension and ionizing radiation. The Board acknowledges that medical article and treatise evidence may be relevant in certain circumstances, such as when they are combined with an opinion of a medical professional. Sacks v. West, 11 Vet. App. 314, 314 (1998). That has not occurred in this case. Instead, the articles are generalized statements regarding the connection and have not been utilized by any medical professional in this case. The articles also do not discuss whether the association still exists under the same environmental circumstances for a dosage level at or near that of the Veteran. Generic statements concerning only medical possibilities are too general and inconclusive to provide the requisite degree of medical certainty. Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996). Thus, the Board finds that the only competent and credible medical evidence before the Board, as to the claim of service connection for residuals of a cerebral vascular accident due to hypertension caused by ionizing radiation is the opinion of the VA examiner. The examiner referred to the medical literature supporting an association if the radiation is directed specifically at the kidney level as is done in bone marrow transplant patients and then radiation nephropathy can occur and that includes resulting hypertension. The doses that the Veteran received, however, do not fit the picture of exposure, nor was the radiation directed towards the kidney. Further, evidence in service showed normal kidney function. Furthermore, the VA examiner has provided the most probative evidence and the Board assigns it the most weight as the examiner's report specifically addresses the question of a link to service In light of the foregoing, the Board finds that the opinion of the VA examiner as persuasive evidence against the claim. As the VA examiner applied medical analysis to the significant facts of the case to reach the conclusion expressed in her opinion that specifically addressed the question of a link to service, the Board finds the evidence competent and credible and highly probative on the material issues of fact, pertaining to the diagnosis and cause of a current disability of residuals of the cerebral vascular accident, which opposes, rather than supports, the claim. Accordingly, the weight of the medical evidence is against an association or link between any current disabilities of residuals of a cerebral vascular accident, and service, including ionizing radiation. The preponderance of the evidence is against the claim of service connection on the applicable theories of service connection, and the benefit of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Service Connection for Nerve Disabilities of the Right and Left Arm The entrance examination in February 1986 did not include a history of any joint pain, neuritis, or other symptoms relating to the arms. The physical examination was normal. In December 1988, the Veteran sought treatment after he fell through an open hatch. He had complaints concerning his right arm, upper back, and right hip. The medical provider noted an abrasion in the upper right arm and upper back. The Veteran had free range of motion without pain and the right arm was neurovascularly intact. The separation examination in January 1990 was normal and the Veteran gave a negative history for neurological problems or any other problems with his arms such as joint pain. He stated his health was good. The Veteran, however, stated that as to the December 1988 incident, he hurt both arms in the accident. He also stated that because the USS Los Angeles would be jostled by the sea, he would be thrown off balance and frequently hit his elbows. He also frequently hit his elbows while climbing down the ladder to exit the fly bridge. He now contends that he has trouble holding objects and driving due to his arm nerve disabilities. After service, the Veteran was evaluated at VA in August 2006 for complaints regarding his left arm and the physician stated it was an injury related to his submarine service. The history stated the Veteran repeatedly injured his left elbow and since that time has had numbness and pain in the ulnar distribution, which has progressively worsened. The Veteran dropped objects with his left hand if he extended the left arm. The physician found very mild weakness in the left hand but could not detect a specific sensory deficit. Otherwise, the left arm examination was normal and no history or findings of the right arm were noted. An X-ray revealed a tiny olecranon spur. There were no acute fractures or significant degenerative changes. In January 2007, an EMG consult resulted in a diagnosis of left ulnar entrapment at the elbow. In a VA examination in October 2010, the Veteran reported that submarine duty resulted in him frequently hitting both elbows on the side. He was told it was an occupational hazard. The right side hurt worse than the left. The Veteran reported pain since service and that he has been told he has arthritis. At the present time, the Veteran reported bilateral aching and sharp pain in the elbows three times a week. Sometimes he gets a zinger down the right forearm to the ulnar aspect of the right hand, but not the left. He asserted symptoms are worse in the right arm compared to the left. Upon physical examination, the Veteran had 4 +/5 motor strength throughout. He had loss of sensation in his left extremities. Reflexes were normal and he had normal motion for both elbows. The Veteran did have a positive Tinel side at the ulnar groove. There was no tenderness or swelling. The diagnosis was right arm ulnar neuropathy by history and physical and left ulnar neuropathy as documented by the EMG in January 2007. The examiner stated ulnar neuropathy is a peripheral issue and unrelated to his cerebral vascular accident. The examiner also noted the in service injury where the Veteran fell through a hatch. There is no evidence of any injury to the right ulnar nerve at that time and specifically to the right elbow. There was no further mention of any right arm problem for the remainder of service or at separation which implied that the abrasions healed. There is also no evidence of an ongoing problem since separation. The examiner therefore concluded that it was less likely than not that the fall through the hatch in December 1986 caused or aggravated any right arm nerve damage. There were no opinions offered as to the left arm. In June 2011, the Veteran was provided a second VA examination. He reported injuring both elbows when he fell down a hatch in December 1986 and asserted it resulted in a lot of swelling and pulsating pain down the arms. The examiner noted the documentation in the service treatment records for the December 1986 fall and that there was a lack of follow-up treatment or ongoing problems for either elbow. There was no mention of any condition in either elbow or any neurologic condition in the upper extremities. The examiner also noted the Veteran at separation stated he was in good health and denied specific problems such as a painful elbow or neuritis. There were no records of an ongoing right or left elbow condition or neurological condition until August 2006. The Veteran reported that a physician interpreted an x-ray at that time as showing an old fracture or chip in the elbow that could worsen over time. The examiner noted the x-ray referred to a tiny olecranon spur in the left elbow and that the EMG demonstrated compression of the left ulnar nerve. The Veteran described symptoms of burning, tingling, and numbing in both arms down into his hands. The arms appear equally painful. Upon examination, motor strength was equal, 5/5, in both extremities with normal muscle tone and bulk. He did have a sensory deficit in the left arm, but the right arm was normal. His reflexes were normal. There was a positive Tinel's sign on the left but not the right. The range of motion in either arm was normal. The examiner diagnosed left ulnar neuropathy but that no diagnosis could be provided for the right arm. The examiner noted that the Veteran had been scheduled for an EMG/NCS, but the Veteran refused. The examiner stated, however, that he believed such a study would not add any value as his left arm already had documented with ulnar neuropathy and even if the right arm did reveal neuropathy, the examiner concluded it would not lead him to conclude that the Veteran had an arm nerve disability related to service. The examiner stated that there was no documentation of a left elbow injury and, as to the right arm, there was no ongoing follow-up for a chronic right upper extremity condition. On his separation examination, the Veteran denied chronic illnesses or problems with his arm nerves, shoulders, or elbows. Given the absence of a chronic problem in service and the lack of medical treatment until at least 2006, the examiner could not establish a cause or relationship with any symptoms that he has currently to any injury, disease, or event that occurred in service. Therefore, the examiner concluded that any left ulnar neuropathy and any current right arm symptoms were not caused by or related to any specific injury the Veteran had in service. In March 2012, the Veteran had X-rays performed and the treatment notes indicate the Veteran had mild degenerative joint disease of the elbow although it was unclear which elbow was involved. After reviewing the foregoing evidence, the Board has concluded that the Veteran does not have a neurological disability related to his arms connected to service. While there is evidence that the Veteran has left ulnar neuropathy, the Board has also concluded that it did not have its onset or it related to service. As to the right arm, the Board finds that the evidence does not support he has a current nerve disability of the right arm. The Board recognizes that the Veteran believes he has a condition that has caused him pain in his arms since separation. The Veteran is competent to testify to the events in service and after, including when he developed pain, weakness, numbness, and tingling. 38 C.F.R. § 3.159. The Board thus finds that the Veteran's statements are credible but the question is whether the Veteran currently has a disability due to service. For the same reasons expressed above regarding his cerebral vascular accident disability, the Board has concluded that, as a lay person, the Veteran, while credible to describe his symptoms and their onset, is not competent to render a diagnosis of a nerve disability to either arm, as a diagnosis requires interpretation of symptoms, and clinical and diagnostic tests, such as X-rays and laboratory tests, which requires medical knowledge. Therefore, the Veteran's assertion or opinion that he has an a neurological disability is not competent evidence and to this extent his statements and testimony are not admissible as evidence of the presence or diagnosis of a nerve disability in either arm since service based on continuity or as an opinion based on causation. The Veteran, as a lay person, is competent not only to identify a simple medical condition, but also a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As for the Veteran relating symptoms that later support a diagnosis by a medical professional, the Veteran points to the opinion of the physician in August 2006 that attributed his left elbow symptoms to the Veteran's submarine service. That examiner, however, relied upon the history provided by the Veteran and did not appear to have the benefit of reviewing the service treatment records. The Veteran's service treatment records demonstrate he had an injury only to the right arm, not the left, and there was no notation of injury to the left arm or of an ongoing chronic problem including the separation examination. The physician did not account for the service records demonstrating only a right arm injury. It also was a general assertion of a relationship to service without any further specificity or rationale. A bare conclusion, even one reached by a medical professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). The Court has held that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). Given the discrepancy between the medical evidence from service of a right elbow injury, and the basis of the treating physician's opinion, the history from the Veteran, of injury to the left elbow in service, and that the physician offers little specific discussion of explaining how reached his opinion, the Board assigns relatively little probative value to the opinion. As to the claim of service connection for right upper extremity peripheral neuropathy, the Board notes first that there has not been any diagnosis of a neurological disorder such as peripheral neuropathy of the right upper extremity, including the elbow. In addition, except for one instance of a positive Tinel's sign which has not been replicated, including the June 2011 VA examination, the right arm has been normal upon examination. No sensory or motor deficits or other objective findings have been demonstrated and the right arm has had normal function. There has not been any diagnosis of a nerve disability such as ulnar neuropathy of the right arm. While there was documentation of an injury in service, it appeared limited to an abrasion and examination at that time indicated normal elbow motion and that the right arm was neurovascularly intact. As the examiners have noted, there was no evidence of follow up treatment after the December 1986 fall and no evidence of a chronic condition. Finally, the Veteran did not make any complaints at separation and the examination was normal. No further problems were documented until April 2006 when the Veteran sought treatment for his left elbow. No treating physician since separation, other than the one previously discussed, has reached a diagnosis of a neurological disorder such as peripheral neuropathy, and/or any other right arm nerve disability that is caused by or otherwise related to service. Although an injury to the right arm is documented in service, this alone is not enough to establish service connection, there must be a current disability resulting from the conditions. Chelte v. Brown, 10 Vet. App. 268, 271 (1997). In the absence of evidence of current right arm nerve disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There is also insufficient evidence of a nerve disability of the right arm at any point during the claim or appeal period. McClain v. Nicholson, 21 Vet. App. 319 (2007). As to the left upper extremity, there is a current diagnosis of left upper extremity peripheral neuropathy, as noted, given the absence of documentation in service, and the absence of symptoms, diagnosis, or treatment after service for many years, the experts have concluded that the current left ulnar neuropathy is not related to service. The Board recognizes that documentation for a service injury is not required, Buchanan, supra, but rather, it has weighed the negative evidence of the treating medical records against the Veteran's statements that injury to the left elbow occurred in service. The Board notes that, in the absence of demonstration of continuity of symptomatology, or a competent medical nexus opinion, the initial demonstration of current disability years after service is too remote from service to be reasonably related to service. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (It was proper to consider the Veteran's entire medical history, including a lengthy period of absence of complaints). Turning to the competent negative medical evidence before the Board, the Board notes the unfavorable medical opinions of the VA examiners are well reasoned, detailed, provide a rationale that is consistent with other evidence of record, and included reviews of the claims file and the Veteran's symptoms. In light of the foregoing, the Board finds that the opinions of the various VA examiners as persuasive evidence against the claims for service connection for a nerve disability in either arm. As the VA examiners applied medical analysis to the significant facts of the case to reach the conclusion expressed in their opinions, the Board also finds the evidence competent and credible and highly probative on the material issues of fact, pertaining to the diagnosis and cause of a current disability of the right and left arm nerve disorders or the relationship to service, which opposes, rather than supports, the claim. Accordingly, the weight of the medical evidence is against an association or link between any current disabilities of the right and left arm nerve disorder and service, including the documented injury and fall in 1986. The preponderance of the evidence is against the claim of service connection on the applicable theories of service connection, and the benefit of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for residuals of a cerebral vascular accident, to include as a result of exposure to ionizing radiation, is denied Entitlement to service connection for a right arm nerve disability is denied. Entitlement to service connection for a left arm nerve disability is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs