Citation Nr: 1309940 Decision Date: 03/25/13 Archive Date: 04/02/13 DOCKET NO. 10-47 037 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to service connection for an undiagnosed illness to include joint pain and memory loss. REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD James A. DeFrank, Counsel INTRODUCTION The Veteran had active service from September 1988 to September 1992. This matter came before the Board from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In August 2012, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at the RO; a copy of the transcript has been associated with the record. FINDINGS OF FACT 1. The Veteran had active service in the Southwest Asia Theater of operations during the Persian Gulf War. 2. The competent and probative evidence of record indicates the Veteran's joint pain is due to a diagnosable disorder and as such, is not due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness. 3. The evidence of record does not support a finding that the Veteran has memory loss resulting from undiagnosed illness that was shown during active service or currently manifested to a compensable degree. CONCLUSION OF LAW Memory loss and joint pain disabilities were not incurred in or aggravated by service, nor are they due to an undiagnosed illness as a result of service in the Southwest Asia Theater during the Persian Gulf War. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and 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. Notice should be sent prior to the appealed rating decision or, if sent after the rating decision, before a readjudication of the appeal. A Supplemental Statement of the Case, when issued following a notice letter, satisfies the due process and notification requirements for an adjudicative decision for these purposes. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided notice to the Veteran in an October 2009 letter, prior to the date of the issuance of the appealed December 2009 rating decision. The October 2009 letter explained what information and evidence was needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The letter also provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter on appeal. Pertinent medical evidence associated with the claims file consists of service, VA treatment records and the reports of April 2010 VA examinations. The April 2010 VA examination reports reflect that the VA examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted an appropriate evaluation of the Veteran, and rendered an appropriate diagnosis and opinion consistent with the remainder of the evidence of record. As such, the Board finds that the April 2010 VA examination reports are sufficient upon which to base a decision with regard to this claim. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Also of record and considered in connection with the appeal are the various written statements provided by the Veteran and by the Veteran's representative on his behalf as well as the Veteran's August 2012 hearing testimony. The Board finds that no additional RO action to further develop the record on the claim is warranted. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (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"). Under 38 C.F.R. § 3.317 , service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2016. See 76 Fed. Reg. 81834 (Dec. 29, 2011) (codified at 38 C.F.R. § 3.317(a) (1) (2012)). For purposes of 38 C.F.R. § 3.317 , there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. at 8-9. Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a) (5) (2012); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a) (2) (ii) (2012). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. §3.317(a) (3) (2012). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b) (2012). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a) (4) (2012). The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Factual Background The Veteran does not contend that his current claimed disabilities were directly incurred in service. Rather, he claims that he has memory loss and a joint pain condition that are due to an undiagnosed illness relating to his service in the Persian Gulf. He testified that he did not experience joint pain while in service, but instead began to experience this pain within a year of his separation from service. He specified that he did not sustain any trauma that caused this joint pain. The Veteran also testified that he did not experience memory loss in service, but its onset was rather within a year of his separation. His service treatment records are negative for any complaints or diagnoses of joint pains or memory loss problems. He was involved in a motor vehicle accident in September 1990 where he suffered a mild contusion of the right mandible and a contusion of the right elbow. However, no x-rays were necessary. A September 1992 treatment report noted that the Veteran denied any significant health problems and his September 1992 separation examination was normal. The Veteran underwent a VA Gulf War examination in April 2010. He presented with complaints of painful knees and shoulders which began shortly after his return from the Persian Gulf. The pain has been intermittent with remissions since its onset. X-rays of the left shoulder were normal but x-rays of the right shoulder revealed right acromioclavicular (AC) degenerative joint disease. X-rays of the bilateral knees demonstrated minimal degenerative change, osseous changes at the anterior tibial tubercles likely the sequela of Osgood Schlater disease and osseous excrescences extending from the anterior superior patella. The diagnosis was bursitis of both shoulder and musculoligamentous strain of both knees. The examiner noted that all diagnoses were stated precisely and there was no lack of a diagnosis. The examiner indicated that at this time, the Veteran appeared to have longstanding joint pains, specifically with the shoulders and knees, but has never seen anyone since his military time concerning any joint complaints. However, joint complaints are quite common, especially with repetitive lifting, bending and repetitive use. Therefore, these were certainly not undiagnosable illnesses. There appeared to be no unknown diagnoses and certainly no unknown diagnoses at this time related to both shoulders and both knees. However, as to whether they are specifically secondary to service from so many years ago, it would be impossible to state because he had never seen anyone over the years. Therefore, there appeared to be no specific joint pains that are undiagnosable and there appears to be no unexplained chronic multisymptom illnesses as the above diagnoses of the 4 joints appear to be due to known diagnoses. The examiner concluded that it would be medically impossible to determine whether these are related to any specific exposure or event occurred in Southwest Asia. The Veteran underwent a neurological VA examination in April 2010 for his claimed memory loss. It was noted that the Veteran had service in the Persian Gulf and reported short term memory loss. The Veteran noted subtle lapses in his attention and concentration abilities both at work and at home. He reported that his memory problems first began very near the time he left the Marine Corps in 1992. The examiner noted that the Veteran's responses to the Shipley test produced a composite score of 111 which suggested overall cognitive functioning in the average to above average range. Further, his responses to a test sensitive to an examinee's motivation and effort were well within normal limits suggesting that the results were likely an accurate reflection of his neurocognitive functioning. On Attention based test, the Veteran overall scored typically in an average and at times high average range on measures of sustained attention. The only discrepancy was a single test requiring rapid visual association and percetuomotor speed. However, there was no consistent finding of deficits in sustained auditory and visual attention among the tests used here. On Language based tests, there was no significant evidence of significant language deficit demonstrated in this testing. His Visual Spatial/Constructional ability ranged from average to above average. On Memory, the examiner noted that overall the Veteran "did quite well". His memory index score was in the average to above average range of memory functioning. In his efforts to learn a word list over multiple trials and to retain that list after being confronted with an interference list, his scores ranged from average to below average. He was average in his immediate and his delayed recognition of visual shapes. He was consistently above average in his immediate and delayed recall of contextual verbal information that one might typically encounter in daily living. He was above average in his immediate recall of this type of information and average in his delayed recall of that information. His working memory index score suggested his ability to hold information in temporary storage in order to complete a task ranged from the average to high average range. The examiner concluded that for the purposes of this testing, the Veteran showed no signs of memory impairment. The examiner noted that on the examination, the Veteran participated in an interview and multiple neurocongitive screening tests to explore his subjective report of attention concentration and short-term memory problems. Findings from this testing suggests average to above average overall general cognitive functioning. He showed overall average to above average performance in his sustained attention language or visualspatial abilities. The examiner also noted that it was very notable for the issue at hand that the Veteran's index score on a comprehensive memory battery was in the above average range. He also showed no evidence of deficits in executive system functioning. He did show a less than expected performance on one motor functioning task (dominant hand, grooved pegboard) but several other task sensitive to motor speed were within normal limits or above average. The Veteran genuinely appeared distressed about the status of his marriage and he openly admitted that he was preoccupied with this concern. The examiner opined that there was some possibility then, that the Veteran's subjective concentration and memory lapses may be related to the marital discord which his narrative indicates that he has been experiencing for quite some time (waxing and waning in intensity over the past 10 years). In an August 2012 letter, a private rheumatologist noted that the Veteran presented with complaints of pain in his shoulders, hips, knees and ankles which had been ongoing since 1992. The diagnosis was myofascial pain, bicipital tendonitis and hip joint pain. The rheumatologist noted that the Veteran had about 4 of the old tender points that is used for diagnosing fibromyalgia and actually had some spasm around the trapezius muscle bilaterally. Analysis Under the circumstances of this case, the Board concludes that service connection for an undiagnosed illness to include joint pain and memory loss is not warranted. As a threshold matter, the Board notes that military records reflect that the Veteran had active military service in the Southwest Asia Theater of Operations during the Persian Gulf War. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. The law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service, discussed above, thus are applicable in this case. Regarding the joint pain component of the claim, there is a current diagnosis of bursitis of both shoulder and musculoligamentous strain of both knees as determined by the April 2010 VA examiner. To the extent that the Veteran contends that bursitis of both shoulder and musculoligamentous strain of both knees is an illness subject to presumptions provided to veterans who served in the Persian Gulf, bursitis of both shoulder and musculoligamentous strain of both knees is not an undiagnosed illness or a medically unexplained chronic multi symptom illness. Hence, presumptive service connection is not warranted. The Board notes that in his August 2012 letter, the private physician noted that the Veteran had about four of the old tender points that are used for diagnosing fibromyalgia. As noted above, under 38 C.F.R. § 3.317, a medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes fibromyalgia. However, the August 2012 private rheumatologist did not diagnose the Veteran with fibromyalgia and there is no evidence in the record of a fibromyalgia diagnosis. Additionally, the April 2010 VA examiner noted that x-rays revealed right shoulder AC degenerative joint disease and minimal degenerative change of the bilateral knees. The April 2010 VA examiner also specifically determined that all diagnoses were stated precisely and there was no lack of a diagnosis. The examiner concluded that there appeared to be no unknown diagnoses and certainly no unknown diagnoses at this time related to both shoulders and both knees. Thus, while the Veteran contends that his joint pain is the result of an undiagnosed illness incurred in Southwest Asia, as evidenced by the April 2010 VA examination, the Veteran's orthopedic complaints stem from a diagnosable disorder, namely bursitis of both shoulders and musculoligamentous strain of both knees. As these disorders have been diagnosed, the Board concludes that the special provisions pertaining to undiagnosed illnesses are not applicable, and service connection for joint pain cannot be granted under the presumptive provisions of 38 U.S.C.A. §1117 and 38 C.F.R. § 3.317. See 38 C.F.R. § 3.317 (2012). In cases where a Veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. §§ 1110 and 1131 are warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (specifically addressing claims based on ionizing radiation exposure). Thus, the presumption is not the sole method for showing causation. However, where the issue involves a question of medical diagnosis or causation, as presented here, a claimant must establish the existence of a disability and a connection between the Veteran's service and the disability. Regarding direct service connection, as determined above, the first element of service connection is satisfied as the Veteran has a diagnosis of bursitis of both shoulder or musculoligamentous strain of both knees. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). The Veteran's service treatment records were negative for any complaints, treatment, or diagnoses of any joint pain and the Veteran has not asserted that his joint pain originated during service. However, the Board must consider the lay assertions as to his pains having their onset close to his separation from service as lay statements may be competent to support claims for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). See also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). However, the lay assertions as to his pains having their onset close to his separation from service are directly contradicted by the contemporaneous service and medical evidence of record. These contemporaneous documents are afforded significant probative weight, since they were created at the time of service or at the time of medical treatment, as compared to statements given many years later. Notably, while the Veteran contends that his joint pains began within a year after his service in the Persian Gulf, the Board notes that the Veteran was not diagnosed with a shoulder or knee disability until many years after service and there was a significant period between his service and his post-service complaints where the medical record was silent for complaints of a shoulder or knee disability. Thus, the Board concludes that the weight of the evidence is against a finding of any continuity of symptomatology. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000). Moreover, there is no competent evidence or opinion even suggesting that there exists a medical nexus between current bursitis of both shoulder or musculoligamentous strain of both knees and the Veteran's military service. In fact, the April 2010 VA examiner, which is the only opinion addressing the etiology of the Veteran's bursitis of both shoulder or musculoligamentous strain of both knees disabilities, concluded that it would be medically impossible to determine whether these are related to any specific exposure or event occurred in Southwest Asia. Neither the Veteran nor his representative has identified, presented, or alluded to the existence of a medical opinion that establishes a relationship between a knee and shoulder disability and service. As there is no competent opinion linking the current disability to service, the preponderance of the evidence is, therefore, against the claim for entitlement to service connection for joint pain on a direct basis. Regarding the memory loss component of the claim, the Board finds that based on the above evidence, service connection is not warranted. The Veteran contends that he has memory loss due to an undiagnosed illness. The Board finds a preponderance of the evidence is against finding a current memory loss disability, and a preponderance of the credible evidence of record is against finding a qualifying chronic disability for which service connection is warranted. In reaching this conclusion, the Board finds the April 2010 VA neurological disorder examination to be the most probative evidence of record. As noted above, the April 2010 VA examiner concluded that the Veteran showed no signs of memory impairment. This opinion was provided by a medical professional who is qualified through education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159(a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). This opinion was also based upon review of the claims folder, including the Veteran's service treatment records and post-service medical evidence as well as an interview of the Veteran and multiple neurocongitive screening tests to explore his subjective report of attention concentration and short-term memory problems. The report discusses the Veteran's pertinent medical history and includes a thorough neurological examination which found that there were no signs of memory impairment. Therefore, the Board finds the April 2010 VA examiner's opinion to be highly probative to determining whether the Veteran has a current memory loss disability. The Board again notes the Veteran's contentions regarding the etiology of his claimed joint pain and memory loss disabilities. To the extent that the Veteran himself contends that a medical relationship exists between his claimed current disabilities and service, the Board again acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). In the instant case, however, the Board finds that bursitis of both shoulder and musculoligamentous strain of both knees and memory loss are not disabilities subject to lay diagnosis as these diagnoses require medical training. More significantly, the Veteran and his representative do not have the medical expertise to provide an opinion regarding the knee and shoulder disability etiology or whether a current memory loss disability exists. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Additionally, the VA examiners provided a detailed rationale in support of their opinions and cited to the relevant evidence. For this reason, the VA examiners opinions are the most probative evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that a factor for assessing the probative value of a medical opinion includes the thoroughness and detail of the opinion). Thus, the Veteran and his representative's lay assertions that there is a relationship between his joint pain and memory loss and an undiagnosed illness are not sufficient in this instance and are outweighed by other probative evidence of record. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board concludes that, for the reasons set forth above, that the preponderance of the evidence is against the claim for service connection for an undiagnosed illness to include joint pain and memory loss. Thus, the reasonable doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for an undiagnosed illness to include joint pain and memory loss is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs