Citation Nr: 1313166 Decision Date: 04/19/13 Archive Date: 05/02/13 DOCKET NO. 08-09 869A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for left hand degenerative changes, to include as secondary to service-connected residuals of a fracture to the 4th right metacarpal. 2. Entitlement to service connection for right hip degenerative joint disease, to include as secondary to service-connected residuals of a lacerated wound of the right upper leg and popliteal region. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Andrew Mack, Counsel INTRODUCTION The Veteran served on active duty from June 1973 to May 1979. This appeal comes to the Board of Veterans' Appeals (Board) from a May 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. These matters were before the Board in October 2011, and were remanded. They have been returned for further appellate consideration. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. FINDINGS OF FACT 1. Neither a left hand disability nor a right hip disability is directly related to the Veteran's period of service. 2. Left hand degenerative changes were not caused and have not been aggravated by the Veteran's service-connected residuals of a fracture to the 4th right metacarpal. 3. Right hip degenerative joint disease was neither caused by, nor aggravated by, the Veteran's service-connected residuals of a lacerated wound of the right upper leg and popliteal region. CONCLUSIONS OF LAW 1. The criteria for service connection for left hand degenerative changes, to include as secondary to service-connected residuals of a fracture to the 4th right metacarpal, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309(a) (2012). 2. The criteria for service connection for right hip degenerative joint disease, to include as secondary to service-connected residuals of a lacerated wound of the right upper leg and popliteal region, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist After review of the claims file, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions in this case with respect to the issues on appeal. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). The information contained in December 2006 and January 2008 letters satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Moreover, the Veteran was notified of regulations pertinent to the establishment of an effective date and disability rating in the January 2008 letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the January 2008 notice letter was provided subsequent to the initial RO determination in May 2007, after issuance of the letter and opportunity for the Veteran to respond, an April 2008 statement of the case (SOC) readjudicated the claims. Hence, the Veteran is not shown to be prejudiced by the timing of this notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC, is sufficient to cure a timing defect). The Veteran's service treatment records, VA medical treatment records, and identified private medical records have been obtained. Also, the Veteran was provided VA examinations in April 2007 and May 2012. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2012). These examinations and reports were adequate because, along with the other evidence of record, they provided sufficient information to decide the appeal and sound bases for a decision on the Veteran's claims. The examination reports were based on examination of the Veteran by examiners with appropriate expertise who reviewed relevant medical records. 38 C.F.R. § 3.159(c)(4) (2012); Barr v Nicholson, 21 Vet. App. 303 (2007). The Board notes that the Veteran has not been afforded a VA examination or opinion regarding the question of whether his claimed right hip disability is directly related to his period of service. However, the Federal Circuit Court of Appeals (Federal Circuit) has recognized that there is not a duty to provide an examination in every case. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Rather, the Secretary's obligation under 38 U.S.C. § 5103A(d) to provide the Veteran with a medical examination or to obtain a medical opinion is not triggered unless there is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability. See McLendon v. Nicholson, 20 Vet. App.79, 81 (2006). As explained below, the Board finds that the evidence does not indicate that there is any clinically ascertainable disability during the pendency of the claims or appeal that might be directly related to any in-service disease, injury or event. Furthermore, significantly, as discussed below, the Veteran has not contended that any right hip disability, including right hip degenerative joint disease, is directly related to his period of service. Therefore, remand for another VA examination is not warranted. See 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Moreover, the RO has at the very least substantially complied with the Board's October 2011 remand instructions. The Veteran was provided adequate VA examinations of his left hand and right hip in May 2012, by a physician with appropriate expertise, the report of which adequately answered the Board's questions, and which, along with the other evidence of record, provided sufficient information to decide the appeal. Under these circumstances, the Board finds that there has been substantial compliance with its remand instructions, and an additional remand to comply with the Board's directives is not required. See D'Aries v. Peake, 22 Vet. App. 97, 104-106 (2008); Stegall v. West, 11 Vet. App. 268 (1998). There is no indication in the record that any additional evidence relevant to the issues on appeal is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield, 20 Vet. App. at 543; see also Dingess/Hartman, 19 Vet. App. at 486. All of the evidence in the Veteran's claims file has been thoroughly reviewed. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence, and on what the evidence shows or fails to show with respect to the matters on appeal. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within a prescribed period following discharge from service; the presumptive period for arthritis is one year. 38 C.F.R. §§ 3.307, 3.309(a). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim for such diseases. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both 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"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen, 10 Vet. App. 183. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. As reflected in his December 2006 claim, the Veteran contends that he has a left hand disability secondary to his service-connected residuals of a fracture to the 4th right metacarpal, and a right hip disability, secondary to his service-connected residuals of a lacerated wound of the right upper leg and popliteal region. While service treatment records reflect that the Veteran incurred a fracture of the 4th metacarpal of the right hand in December 1976, they reflect no complaints or findings of any left hand problems. They further reflect treatment for complaints of back pain following an automobile accident in January 1977. In March 1978 and April 1978, the Veteran complained a lump under the skin in the pelvic area of his right side, and was noted to have had a swollen right inguinal lymph node. December 1978 to March 1978 records reflect treatment for an old right knee laceration secondary to a car accident, and the impression was post traumatic neuritis of the right popliteal fossa. At the time of his January 1979 examination for separation from service, the Veteran was noted to have had a normal clinical evaluation of the upper and lower extremities, abdomen, and viscera, no problems of the left hand, right hip or inguinal region were noted, and he denied having ever had arthritis. The Veteran reported a history of a right leg laceration, asserted that he experienced cramps in the right leg when exerting himself, and described experiencing worsening lower back pain. Post-service VA treatment records reflect that, in August 1980, the Veteran complained of right leg pain status post laceration in 1976. He was noted to have had trauma to the right popliteal area, and he complained that over the past one and a half years the pain had worsened and he had a burning sensation down the back of the leg to the ankle and up the thigh and back. In September 1980, the Veteran complained of back pain radiating into his right leg for the past four days, and was assessed with rule out sciatic pathology and low back syndrome. Later in September 1980, the Veteran was noted to have had a history of laceration to the right popliteal fossal region, and reported that he had developed burning pain over the popliteal fossa. In October 1980, the Veteran reported being in involved in a car accident in June 1976, injuring the right popliteal area, and having a greater deal of pain since the injury; he was noted to have had a well-healed, tender scar over the popliteal area, and reported persistent pain over the right popliteal area, with no other major medical problems. In March 1981, the Veteran was again treated for pain in the popliteal area. October 1981 letters from the Veteran's private physician, Dr. K., reflect that the Veteran was seen for complaints of pain in the right leg with a burning quality, beginning behind the right knee and extending up into the hip and down to the foot, with occasional numbness of the right leg, which began in June 1976 after a traffic accident, where his right calf was lacerated by a piece of steel. It was noted that the Veteran was given an epidural injection with a local anesthetic, which sufficiently improved his condition, and he was directed to prevent further strain to his back. July to August 1982 VA hospital notes reflect that the Veteran complained of pain in the right knee and hip. It was noted that the Veteran had sustained laceration to the soft tissues of the back of the knee and that he had been having pain in the right knee and right out hip area on and off, worsened by physical activity. X-ray of the right hip showed some hypertrophy of the lateral aspect. The discharge diagnosis was status post soft tissue trauma to the right knee. The report of a VA examination in November 1984 reflects that the Veteran reported continuing burning sensation on his right knee and on the laceration behind the right knee, as well as lower back pain. The diagnosis was residual scar of the upper leg and popliteal region. The report of a July 1987 VA examination reflects that the Veteran had pain localized in the right popliteal fossa, with occasional rundown to the right knee, pressure sensations behind the right knee on any prolonged standing, and pulling sensation about the right hip at times. The diagnoses were scar, lacerated wound of the right thigh with pain problems, and tender nodule of the right popliteal fossa. The report of an April 1993 VA examination reflects that the Veteran reported residual pain behind the right knee and right leg radiating down into the right foot, associated at times with a numbness. It was noted that he worked as a letter carrier for the post office, and the diagnosis was status post deep laceration of the right knee and leg with complaint of residual pain, numbness, and weakness of the lower extremity. The report of a September 1998 VA peripheral nerves examination reflects the impression of the examiner that the Veteran had some symptoms of right lower extremity sensory loss, and that his examination was most suggestive of a mild chronic lumbar radiculopathy, primary involving L5, with sensory symptoms, but no confirmatory sensory abnormalities, but abnormal mechanical findings and abnormal gait. The report of a February 1999 examination addendum reflects the opinion that the most likely cause of the Veteran's right leg numbness appeared to be, almost exclusively, a lumbar radiculopathy with very little involvement from a laceration in the popliteal region. VA treatment records reflect that in March 2006, nearly three decades removed from the Veteran's military service, he began complaining of left hand pain and occasional swelling of the fingers. The Veteran stated that he was mostly using his left hand to avoid pain on his right, which he had in a sling due to carpal tunnel syndrome. He stated that he worked in the postal service and had to lift heavy boxes, mainly using his left hand, and that the hand was also affected by excessive efforts. On examination, the Veteran had diminished strength and pain to finger joints and wrist level of the left hand. In July 2006, the Veteran reported that he did not know what happened, but that his right hip now hurt. He denied trauma, and reported that he pain had begun the day before. The Veteran was treated again for complaints of right hip and left hand pain in September through November 2006, and it was noted that X-rays had shown arthritic changes of both the right hip and left hand. X-rays of the right hip taken in April 2007 also showed mild degenerative changes. The report of an April 2007 VA examination reflects that the Veteran reported hip pain while walking since the previous year, but denied any trauma or injury to the right hip. It was noted that the Veteran pointed to the exact location of the pain at the right inguinal area. The diagnoses were right hip degenerative joint disease and right inguinal tenderness. After reviewing the record and examining the Veteran, the VA examiner opined that the Veteran's current right hip condition was less likely than not related to his service-connected residuals of lacerated wound of the right upper leg and popliteal region. The examiner explained that the Veteran had positive degenerative changes in his right hip as per his X-ray, but noted that while the Veteran reported experiencing general right leg pain in service, no specific right hip pain was ever treated. Moreover, the examiner stated that the Veteran's complaints at the examination were in relation to his right inguinal area and not to his hip. The examiner noted that the right inguinal area was tender to palpation, and observed that the Veteran had a history of right inguinal node problems while in service. The examiner further stated that the lacerated wound was only at the popliteal space and no laceration wound was noted above the knee, and that the present complaints of the Veteran were not specific to the right hip, but due to right inguinal pain. In September 2007, the Veteran filed claims for an increased rating for his right leg laceration injury and for service connection for degenerative joint disease and arthritis, as well as radiculopathy secondary to arthritis. In a May 2008 rating decision, a rating of 10 percent for residuals of lacerated wound of the upper leg and popliteal region was continued and service connection for a back condition and right leg radiculopathy were denied. In August 2008, the Veteran requested a new claim for service connection for his back condition, including degenerative disc disease, and associated lower extremity radiculopathy. In a January 2009 rating decision, the RO again denied service connection for a back condition, as well as for radiculopathy of the left leg and right leg as secondary to a back condition. In June 2010, the Veteran again filed a claim for service connection for a back condition, and in a November 2010 rating decision, the RO denied the claim again. The Veteran did not file a notice of disagreement with any of these rating decisions. The report of a May 2012 VA examination reflects that the examiner reviewed the claims file, and that the Veteran denied any inguinal symptoms, but reported right hip pain for the previous five years. On examination, no inguinal hernia was detected, but a moderate sized umbilical hernia and rectal diastasis were noted. The examiner noted pertinent service treatment records, including the Veteran's right leg treatment following an automobile accident, and the right inguinal lymph node, noted in April 1978. The examiner opined that the Veteran's claimed condition was less likely than not related to service, as the Veteran's service and VA medical records did not show any documentation of a right inguinal condition, and the Veteran denied any complaints of any condition in the right inguinal area. It was noted that the Veteran pointed to the right lateral hip area and stated that it hurt. The examiner stated that, due to lack of documentation of right inguinal area pain, the absence of the Veteran's complaint of pain in the area, the absence of radiologic evidence of abnormality in the area, and the absence of clinical findings on examination, there was no inguinal area pain that could be diagnosed. It was noted that the Veteran in his last visit with his primary care provider complained about out his umbilical hernia, which was not the same as an inguinal hernia, but that he did not complain of inguinal hernia or inguinal tenderness and pain. Regarding the Veteran's claimed left hand disability, the Veteran reported pain, numbness and twitching in the hands, and that he had had left hand surgery in Miami. The diagnosis was degenerative changes of the left hand. After reviewing the claims file, including service and post-service treatment records regarding the Veteran's right and left hand, the examiner opined that the Veteran's left hand condition was less likely than not incurred in or caused by in-service injury, event or illness, as treatment records showed minimal degenerative arthritis of the hands, and that the Veteran's carpal tunnel syndrome and fibroma conditions of the hands, including his left hand, were not related to degenerative changes due to the Veteran's service-connected residuals of a fracture to the 4th right metacarpal. The examiner explained that fibroma could be caused by direct injury, but observed that there was no documentation of injury to the left hand during service. The VA physician further stated that degenerative arthritis of the left hand could not be caused by the degenerative arthritis of the right hand, and was usually caused or aggravated by direct trauma and aging. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the Veteran's service connection claims must be denied. Initially, the record does not reflect that either a left hand disability or a right hip disability is directly related to the Veteran's military service. Service treatment records reflect no complaints or findings of any left hand problems; the earliest indication of any left hand problems is a March 2006 VA treatment note reflecting complaints of left hand pain and occasional swelling of the fingers. However, this record was generated more than 25 years after the Veteran's separation from service, and there is no competent medical evidence that even suggests that the degenerative changes in the Veteran's left hand might be directly related to his period of service. Regarding the Veteran's claim for right hip disability, service treatment records, as well as VA treatment records in the years following service from August 1980 to March 1981, reflect that, following his in-service automobile accidents, the Veteran was repeatedly treated for reported pain in the right knee and right popliteal area, and back pain with radiation to the legs. However, these records do not indicate that the Veteran was ever treated for a separately diagnosed or manifested right hip disorder, nor did he ever voice any right hip complaints. The October 1981 letters from Dr. K. reflect that the Veteran's right leg pain extended up into the hip, and the July to August 1982 VA hospital notes reflect that the Veteran reported pain in the right knee and right out hip area on and off. Also, November 1984 to February 1999 VA examination reports reflect such findings and reports of the Veteran as radiating pain throughout the leg and pulling sensation about the right hip at times. However, such complaints and findings were consistently found to have been a manifestation of either a lumbar spine disorder, or the Veteran's right upper leg and popliteal region laceration residuals. For example, Dr. K. related the Veteran's problems to his back, the VA hospital discharge diagnosis in August 1982 was status post soft tissue trauma to the right knee, and the VA examination reports consistently diagnosed scar, lacerated wound, and pain of the right thigh and popliteal area, and eventually reflected that the Veteran's right leg problems were primarily due to lumbar radiculopathy. The record does not reflect any separately diagnosed or separately manifested right hip disorder during this period. The Board notes the denied claims for an increased rating for residuals of lacerated wound of the upper leg and popliteal region, claimed as right leg laceration injury, and for service connection for degenerative joint disease and arthritis, degenerative disc disease, and associated radiculopathy of the left leg and right leg as secondary to a back condition, as described above. Although the Veteran specifically filed these claims and such claims were explicitly denied by the RO, Veteran has not appealed any of these issues, and such issues have not been again raised by Veteran since the time of the most recent denials of those claims. Therefore, no such claims for an increased rating for residuals of lacerated wound of the upper leg and popliteal region, or for a back disability including degenerative disease, or lower extremity radiculopathy, are before the Board at this time. The Board also notes that the July to August 1982 VA hospital notes reflecting that the Veteran complained of right knee and hip pain also reflect that X-rays of the right hip showed some hypertrophy of the lateral aspect. However, the only noted diagnosis related to the Veteran's soft tissue trauma to the right knee, and no separate hip disability was diagnosed. Furthermore, there was no indication in these hospital notes, or elsewhere in the record, that any such noted right hip hypertrophy was in any way related to the Veteran's period of service. Moreover, even if this was taken as evidence of the onset of a current hip disability, it still did not appear until several years after the Veteran separated from service. Moreover, the Veteran was able to work in a physically demanding job for a number of years, and the earliest indication of the current, separately diagnosed right hip disorder, diagnosed as right hip degenerative joint disease, was in July 2006. At the time of that note, the Veteran reported that he did not know what happened, but that his right hip now hurt, and he denied trauma and reported that the pain had begun the day before. On VA examinations in April 2007 and May 2012, the Veteran again related that his right hip problems had begun in 2006, which is more than 25 years after his separation from service. Also, as neither left hand arthritis nor right hip arthritis was shown to be manifested until many years after service, the presumptive service connection provisions of 38 C.F.R. §§ 3.307 and 3.309(a) are not applicable. The Board notes that the April 2007 VA examination report reflects that the Veteran pointed to the exact location of his claimed right hip pain at the right inguinal area. Service treatment records reflect that in March 1978 and April 1978, the Veteran complained a lump under the skin in the pelvic area of his right side, and was noted to have had a swollen right inguinal lymph node. However, while the Veteran was noted to have had pain in the right inguinal region in April 2007, no disorder relating to such pain was diagnosed. In May 2012, the VA examining physician attempted to determine specifically whether the Veteran had any such diagnosed right inguinal disorder. However, while noting the in-service finding of swollen right inguinal lymph node, the examiner determined that the Veteran did not have an inguinal hernia and did not, at that time, complain of right inguinal pain, and that, due to lack of documentation of right inguinal area pain, the absence of the Veteran's complaint for pain in the area, the absence of radiologic evidence of abnormality in the area, and the absence of clinical findings on examination, there was no inguinal area pain that could be diagnosed. The VA examiner, a physician with appropriate expertise, made these determinations after thoroughly examining the Veteran and reviewing the claims file; there is no medical evidence otherwise noting a current diagnosed right inguinal area disorder. Therefore, even assuming that the credibility of Veteran's reports of inguinal area pain in April 2007, the Board finds the May 2012 VA examiner's opinion to be persuasive, and that the Veteran does not have a clinically ascertainable disability of the right inguinal area. VA does not generally grant service connection for symptoms alone, without an identified basis for those symptoms. The VA needs to identify a disability, not symptoms of a disability. Accordingly, service connection cannot be granted for symptoms of a disability. As the weight of the competent and probative evidence reflects that the Veteran does not have, and has not at any point during the pendency of the claims or appeal had, any clinically ascertainable right inguinal area disability, there can be no valid claim for service connection for any such disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); McClain v. Nicholson, 21 Vet. App. 319 (2007). Furthermore, significantly, the Veteran has never claimed disability of the right inguinal region; rather, he has consistently claimed right hip disability. Moreover, significantly, the Veteran has not contended that any left hand or right hip disability is directly related to service. Rather, he has contended that a left hand disability is secondary to his service-connected residuals of a fracture to the 4th right metacarpal, and that a right hip disability is secondary to his service-connected residuals of a lacerated wound of the right upper leg and popliteal region. However, while the record reflects current left hand degenerative changes and right hip degenerative joint disease, the weight of the competent and probative evidence suggests that neither was caused or has been aggravated by any service-connected disability. The only competent and probative opinion of record on the question of whether the Veteran has a right hip disability caused or aggravated by his service-connected residuals of a lacerated wound of the right upper leg and popliteal region is that of the April 2007 VA examiner, who opined that the Veteran's current right hip condition was less likely than not related to his service-connected residuals of lacerated wound of the right upper leg and popliteal region. The Board finds the examiner's opinion to be persuasive. The examiner was a medical expert who reviewed the record and examined the Veteran prior to providing an opinion, and explained that the Veteran's lacerated wound was only at the popliteal space, and that no laceration wound was noted above the knee. In this regard, the record contains no medical opinion or other competent and probative evidence explaining in any way how the Veteran's service-connected residuals of a lacerated wound of the right upper leg and popliteal region might have caused or aggravated any right hip disability, or otherwise supporting the Veteran's claim for a right hip disability in any other way, and neither the Veteran nor his representative have identified any such evidence. Likewise, the only competent and probative opinion of record on the question of whether the Veteran has a left hand disability caused or aggravated by his service-connected residuals of a fracture to the 4th right metacarpal is that of the May 2012 VA examiner, who opined that the Veteran's carpal tunnel syndrome and fibroma conditions of the left hand were not related to degenerative changes due to the Veteran's service-connected residuals of a fracture to the 4th right metacarpal. The Board finds the opinion to be persuasive. Again, the examiner thoroughly reviewed the claims file, specifically citing pertinent evidence in the record, and was a physician with appropriate expertise to make such an opinion. The examining physician explained that fibroma could be caused by direct injury, but that degenerative arthritis of the left hand could not be caused by the degenerative arthritis of the right hand, and was usually caused or aggravated by direct trauma and aging. Again, the record contains no medical opinion or other competent and probative evidence supporting the Veteran's claim for a left hand disability, or explaining how the Veteran's service-connected residuals of a fracture to the 4th right metacarpal might have caused or aggravated any left hand degenerative changes, and neither the Veteran nor his representative have identified any such evidence. The Veteran is competent to report matters within his own personal knowledge, including that he believes he had to use his left hand more than he otherwise would have due to his service-connected residuals of a fracture to the 4th right metacarpal. See Layno, 6 Vet. App. at 469. Also, a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation. See Jandreau, 492 F.3d 1372. However, while the Veteran might believe that his left hand degenerative changes are medically related to his service-connected residuals of a fracture to the 4th right metacarpal, or that a current right hip degenerative joint disease is medically related to a lacerated wound of the right upper leg and popliteal region, these medical questions of causation and aggravation extend beyond an immediately observable cause-and-effect relationship, and require medical expertise to answer. As such, the Veteran is not competent to address etiology in the present case. Finally, the Board notes that while the May 2012 VA examiner did not diagnose any inguinal hernia or other disability of the inguinal area, he diagnosed an umbilical hernia. However, the VA examiner did not relate any such hernia to service or to a service-connected disability, and the record does not reflect any evidence or contention of the Veteran suggesting that any such umbilical hernia might be related to service or to a service-connected disability in any way. Accordingly, the Board finds that the claims for service connection for left hand degenerative changes, to include as secondary to service-connected residuals of a fracture to the 4th right metacarpal, and right hip degenerative joint disease, to include as secondary to service-connected residuals of a lacerated wound of the right upper leg and popliteal region, must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. ORDER Service connection for left hand degenerative changes, to include as secondary to service-connected residuals of a fracture to the 4th right metacarpal, is denied. Service connection for right hip degenerative joint disease, to include as secondary to service-connected residuals of a lacerated wound of the right upper leg and popliteal region, is denied. ____________________________________________ MATTHEW W. BLACKWELDER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs