Citation Nr: 1316121 Decision Date: 05/16/13 Archive Date: 05/29/13 DOCKET NO. 08-18 606 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for bilateral hand and finger disabilities. 2. Entitlement to service connection for bilateral shoulder disabilities. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Nadine W. Benjamin, Counsel INTRODUCTION The Veteran (appellant) served on active duty from December 1966 to December 1968 and from January 1969 to March 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa, which denied the benefits sought. The Veteran testified at a July 2009 Board hearing before the undersigned Veterans Law Judge. The hearing transcript has been associated with the claims file. In January 2010, the Board remanded this claim for additional development. The Board is also satisfied that there was substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In this regard an addendum opinion was obtained and as will be explained below, the Board finds that the opinion is adequate. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The issue of entitlement to an increased evaluation for right wrist tendonitis has been raised by the record (see, March 2013 written brief of the representative) but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Bilateral hand and finger disorders did not originate during a period of military service or within one year of discharge from service, and are not caused by or otherwise related to any incident of active service. 2. A bilateral shoulder disorder did not originate during a period of military service or within one year of discharge from service, and is not caused by or otherwise related to any incident of active service. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hand and finger disabilities have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. The criteria for service connection for bilateral shoulder disabilities have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Board finds that the VCAA duty to notify was satisfied by a letter sent to the Veteran in October 2006 with regard to the claims for service connection decided below. The letter addressed all of the notice elements, including the requirements of Dingess and was sent prior to the initial unfavorable decision by the AOJ in November 2007. The duty to assist was also met in this case. The service treatment records are in the claims file. The Veteran's Virtual VA file has been reviewed. All pertinent VA and private treatment records have been obtained and associated with the file. It is noted that records for treatment for hand and shoulder injuries at the Patuxent River Naval Hospital from October 1971 to December 1971 were not located and records of VA treatment in 1976 were also not located. The RO issued a Formal Finding of Unavailability for the records and so informed the Veteran. He was examined by VA and an adequate VA opinion was provided. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110. 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). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year (three years for active tuberculous disease and Hansen's disease; seven years for multiple sclerosis) from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term "chronic disease" refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki 708 F.3d 1331 (Fed. Cir. 2013) Where a chronic disease under 3.309(a) is "shown as such in service" ("meaning clearly diagnosed beyond legitimate question" Walker v. Shinseki 708 F.3d 1331 (Fed. Cir. 2013) or in the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In cases where a chronic disease is "shown as such in service", the Veteran is "relieved of the requirement to show a causal relationship between the condition in service and the condition for which service connected disability compensation is sought." Walker, supra. Instead, service connection may be granted for subsequent manifestations of the same chronic disease without any evidence of link or connection between the chronic disease shown in service and manifestations of the same disease at a later time. In other words, "there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. If evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not "shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned," i.e., "when the fact of chronicity in service is not adequately supported," then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Walker, supra; 38 C.F.R. § 3.303(b). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. The Veteran contends that all his disabilities for which he is seeking service connection stem from an injury he suffered as a result of a six hundred gallon fuel tank falling on his hands while in service. The Veteran contends that this accident occurred during the course of his duties as an aviation machinist's mate. The Veteran further contends that as a result of the accident he had to be pulled out from under the fuel tank which caused injuries to his wrists, hands, fingers, elbows and shoulders. The service medical records show no complaint, diagnosis or treatment for injuries to the bilateral hands or the bilateral shoulders. On reenlistment examination in January 1970, and on candidate crewmember examination in January 1971, no hand or shoulder disorders were noted. In November 1971, the Veteran was treated for a swollen right wrist with no history of a sprain. He reported a similar episode three months earlier. It was noted that there was no history of trauma. The finding was questionable carpal tunnel. A hand service consult at the Bethesda Naval Hospital dated in November 1971 noted a two day history of right wrist pain with no known injury. It was noted that it resolved spontaneously. X-rays showed no bony pathology. The finding was right flexor carpi ulnaris tendonitis probably due to a strain unnoticed at that time. On reenlistment examination in November 1976, the Veteran reported that he was in good health and taking no medication. He denied having any bone, joint or other deformity and also denied having a painful or trick shoulder. He denied having had any injury. On air crew application in January 1981, his upper extremities were found to be clinically normal. He indicated that he was in good health. He denied having any bone, joint or other deformity and also denied having a painful or trick shoulder. He denied having had any injury, and the examiner noted that other than hearing loss, the Veteran denied any other medical problems. Private records show that the Veteran underwent physical therapy in March 1983 for treatment of the left shoulder, diagnosed as calcific tendonitis. He reported that the left shoulder had been bothering him for 10 to 11 months with gradual onset at that time. He denied any shoulder problem in the past but reported a tendon becoming detached from the bone in the left hand. Private records show that in December 2001, the Veteran was treated for left shoulder pain and he indicated that he had the pain for years. He noted that it got progressively worse about 10 months prior. He reported having been healthy in the past. He stated that about 30 years prior he was lifting a gas tank and his coworker dropped the gas tank and he sustained a traction injury to both upper extremities. X-rays showed Grade III acromion, and some calcification in the rotator cuff. The finding was, possible left carpal tunnel and possible rotator cuff tear left shoulder. In March 2002, he underwent surgery of the left shoulder. In March 2003, the Veteran reported having pain swelling in multiple joints. The examiner reported that it sounded like Raynaud's phenomenon. Arthritis, bilateral hands was found. An April 2003 vascular lab report indicated that the Veteran had hand discoloration and pain suggesting Raynaud's phenomenon. The impression was, normal PVG recording of the right and left second and third digits with abnormal post cold immersion wave form, significant obliteration of this diminution with stellate ganglion block suggesting significant sympathetic component to vasospasm. A nerve conduction study showed mild bilateral carpal tunnel syndromes and left ulnar neuropathy of a mild degree. An EMG of the left upper extremity was normal. A private hospitalization in July 2005 it was noted that the Veteran had chronic pain and stiffness and deformity of his fingers due to osteoarthritis. X-rays showed severe osteoarthritis of multiple joints of the right hand. The finding was, symptomatic severe osteoarthritis of the right third finger. He underwent surgery of the DIP joint of the right 3rd finger. In a November 2006 statement, the Veteran's wife indicated that the Veteran called her from Bethesda Naval Hospital and said he was there after a fuel tank had been dropped into his hands. She reported that they did evaluations and tests and that he had pulled all the ligaments and tendons in his hands, wrists, elbows and shoulders. She indicated that he wore hand and wrist braces for years The Veteran was examined by VA in March 2007. The claims file and the medical records were reviewed. The Veteran related that he had an injury in service when a fuel tank fell and injured him. He reported having to use braces and having problems since that time. The Veteran was examined and the diagnostic impression was, extensive degenerative arthritic changes and/or tendonitis in hands, fingers, shoulders and wrists and lesser of the elbows. The examiner found that the wrist problem was caused by the injury in service. In an October 2007, the March 2007 VA examiner reviewed the prior examination report. It was noted that the X-rays of the elbow and wrists showed no significant arthritis; x-rays of the hands showed moderately advanced osteoarthritis; and x-rays of the shoulder showed mild hypertrophic degenerative changes of the left acromioclavicular joint and the right side showed no shoulder arthritis. It was stated that the final diagnosis should be degenerative joint disease of the fingers and left shoulder; chronic tendonitis of the right shoulder and both wrists; no pathology of the elbows. The examiner again reviewed the records and stated that he felt that a significant injury occurred but from available records, he could not support this other than the one notation that showed a strain injury occurred. It was reported that the Veteran and his wife gave an extensive history of the injury and the transfer to Bethesda that was in the record. The examiner stated that he realized that we can only speculate to some degree what happened but he felt that the one note from the hand department at Bethesda does support that an injury occurred to the right hand anyway. In November 2007 the Veteran was granted service connection for right wrist tendonitis. The Veteran testified before a hearing officer at the RO in March 2008. He stated that his injury occurred in November 1971 and that he was treated at the Patuxent River hospital and then transferred to the Bethesda Naval Hospital and was an outpatient. He stated that he wore braces for two years afterwards and still does. He stated that he was treated in May 1976 at a VA facility for his wrists and shoulders. The Veteran appeared before the undersigned in July 2009. He testified regarding his inservice injury which he said occurred in 1971. He also discussed his current complaints. In February 2010 a VA medical opinion was rendered. The claims file and the medical records were reviewed. The examiner stated that according to the Veteran's claim, both of the upper extremity issues are due to the fuel tank drop that occurred in the early 1970's. The examiner stated that however there are two entries in the service treatment records which appear to be at the Bethesda Naval Hospital and both of these entries stated no history of trauma. The examiner stated that one would imagine that if a 300-600 pound fuel tank fell on someone's hands, that this would certainly be mentioned in the medical records. It was noted that otherwise the rest of the service records are silent and the next entry was in 2001 when the fuel tank incident is brought to light again. It was noted that the Veteran has had upper extremity issues as noted in 2001 and that in the 1983 time frame he had physical therapy for his left shoulder but the reason for the therapy is not present. The examiner stated that it would be resorting to speculation to state whether the disorders are directly related to service. It was noted that the reason for this is because the medical documentation back in that time frame is not consistent with the Veteran's complaints. It was noted that the two entries in 1971 stated no history of sprain and no history of trauma. It was stated that since there is no mention of any injury and the next entries from his post military days are dated in 1983 with no complaints of any specific injuries and then again in 2001 when the fuel tank incident is brought to light, it would be complete speculation to state whether both upper extremities are either caused by the fuel tank incident or directly related to service in general. It was noted that the reasoning behind this is because the two entries from service are not helpful when it comes to resolving these issues. The examiner stated that there is no history of any severe injury nor any injury at all when it comes to the 1971 time frame. The examiner stated that he could not find any aggravating issues because the documentation is not helpful with this. The examiner stated that the method by which the Veteran claims these issues appears to be reasonable, especially with the weight of the fuel tank that he claims but that unfortunately the medical records are not of help. He stated that therefore he found this to be speculation. Discussion The evidence indicates that the Veteran has been currently diagnosed with bilateral shoulder and bilateral hand disorders. The Board finds that service connection is not warranted, however, because the evidence does not indicate that the Veteran's upper extremity disorders on appeal are related to service or any injury incurred therein. There is also no evidence suggesting that any arthritis was diagnosed in service or within a year of the Veteran's separation from service. As noted, there is no evidence of a complaint, diagnosis or treatment for a bilateral hand disorder or a bilateral shoulder disorder due to an injury during service. The November 1971 treatment was for a right wrist sprain and the Veteran has been service-connected for that disorder. The first objective evidence of any shoulder disorder is located in private records in 1983 for left shoulder pain. The first objective evidence of a bilateral hand disorder is in private treatment in 2003, and the first objective evidence of a right shoulder disorder is on VA examination in 2007. These records are several years after the Veteran's separation from active service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). He has been diagnosed with current disorders of the bilateral hands and bilateral shoulder in 2007, found to be extensive degenerative arthritic changes and or tendonitis in the hands, fingers, shoulders and wrists. However, there is no competent evidence of a nexus or connection between any disease, injury, or event in service and the current disabilities. The competent medical evidence of record consists of the findings and the opinion of the VA examiner, a physician, who is qualified through education, training, or experience to offer a medical opinion, and who did so in February 2010. The examiner indicated that it would be resorting to speculation to state whether the disorders in question are related to service. The February 2010 VA examiner determined the Veteran's bilateral upper extremity disorders could not be attributed to service without resorting to speculation. The Board is unable to grant a claim based on speculation. See 38 C.F.R. § 3.102 (distinguishing reasonable doubt from pure speculation or remote possibility); Slater v. Principi, 4 Vet. App. 43, 44 (1993) (upholding Board's rejection of a medical nexus opinion that was based on speculation). The Board finds the opinion is adequate because there is no factual development left to be done. In Jones v. Shinseki, 23 Vet. App. 382 (2010), the Court held that an examination is not inadequate merely because the examiner cannot reach a conclusion without resort to speculation. In general, the Court held that it must be clear on the record that the inability to render an opinion must not be the first impression of an uninformed examiner, but rather an assessment arrived at after all due diligence in seeking relevant medical information that may have a bearing on the requested opinion. Therefore, it must be clear, from either the examiner's statements or the Board decision, that the examiner did indeed consider all procurable and assembled data. Here, the VA examiner indicated that he had reviewed all the available material, including the service treatment records, VA records, and private medicals. The examiner reviewed the Veteran's lay statements as well as the claims folder. In this case, the Board finds that all available, pertinent medical information was presented to, and considered by, the VA examiner. It is noted that records for treatment for hand and shoulder injuries at the Patuxent River Naval Hospital from October 1971 to December 1971 were not located and records of VA treatment in 1976 were also not located. The RO issued a Formal Finding of Unavailability for the records and so informed the Veteran. For the reasons discussed earlier, VA obtained all evidence that could be procured and exhausted all reasonable steps to ensure that no additional records were available. The examiner discussed why he could not provide an opinion without resorting to speculation in detail. Although the VA examiner was unable to offer an opinion without resorting to speculation, the opinion is adequate because the VA examiner considered all the procurable and assembled evidence, the duty to assist in developing the facts having been fulfilled. And while the examiner stated that the method by which the Veteran claims the issues appeared to be reasonable, he went on to qualify that statement by indicating that however, the medical records do not help and that therefore, this would be speculation. The VA examiner's opinion is therefore evidence against the claim of service connection as service cannot be based on pure speculation and speculation does not equate to reasonable doubt. 38 C.F.R. § 3.102. In addition, the Veteran has not submitted any competent medical evidence relating his conditions to service, and although he has reported that such a link exists, as a layperson, he is not competent to comment on the etiology of a medical disorder. As noted, as there is no evidence of any arthritis of the hands or shoulders manifested to a compensable degree within a year of the Veteran's discharge from active military service in 1976, service connection is also not warranted on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309. Moreover, although the Veteran has a diagnosis of arthritis currently, arthritis was not "clearly diagnosed beyond legitimate question" in service and so this is not a case where subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected under section 3.303(b). 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, because there was no diagnosis of arthritis at all in service, there is no diagnosis that might be legitimately questioned so that the Veteran might establish service connection by a showing of continuity of symptomatology under section 3.303(b). Id. Rather, service connection in this case must be established by means of a link or nexus between the arthritis today and a disease or injury in service. 38 C.F.R. § 3.303(a), (d); Walker, supra. The Board points out that the Veteran has contended that he has had bilateral hand and shoulder problems which had their onset during military service and continued since service discharge. However a review of the evidence does not support his contentions. In this regard, the question is whether the Veteran's assertions are credible, as they are inconsistent with the medical findings in the record, to include service treatment records and private treatment records. Those contemporaneous records are more probative because they are closer in time to the events. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (stating that credibility may be impeached by a showing of interest, bias, or inconsistent statements). For example, when he first applied for service connection in 2006, he indicated that the injury to his hands and shoulders occurred in 1973 or 1974on his VA Form 21-526 and again in a written statement describing the event; he later indicated that the date was in 1971. When he was treated in service in 1971 there is no mention of any injury, and in fact two examiners affirmatively indicated no history of injury or trauma. If indeed he had suffered an injury as he describes, it would have been noted during the treatment he received. When he was treated in 1983, there was no mention of any prior injury, and he reported that the left shoulder had been bothering him for only 10 to 11 months prior with gradual onset at that time. In December 2001, the Veteran was treated for left shoulder pain and he indicated that he had the pain for years. He noted that it got progressively worse about 10 months prior. He reported having been healthy in the past. While he stated that about 30 years prior he was lifting a gas tank and his "coworker" dropped the gas tank and he sustained a traction injury to both upper extremities, there was no mention that this happened during his military service. An inservice injury is not mentioned in the medical record until after the Veteran filed his claim. Thus this evidence has little probative value. The Board also finds the Veteran's statements with respect to symptoms during service and the first year after his discharge from service to be not credible, as they are inconsistent with the contemporaneous evidence of record. The Board finds this contemporaneous evidence to be more probative. Further during his testimony before the undersigned he stated that he did not receive treatment for any hand complaints until 1976 and that the shoulders began to bother him in 1979, 1980 or 1981. However on the 1981 Reserve examination, he reported being in good health and denied any history of bone or joint problems, swollen or painful joints or a painful or trick shoulder. The Board notes that the Veteran's spouse is also competent to report what she observes. See Layno, 6 Vet. App. at 469-71; Barr, 21 Vet. App. at 307 -08. However, the Board notes that in her statement she indicates that the Veteran called her from Bethesda Naval Hospital after he had been taken there for an injury and that he had pulled all the ligaments and tendons in his hands, wrists, elbows and shoulders. This evidence is also inconsistent with the contemporaneous evidence. Thus, continuity of symptomatology is not demonstrated. The Board acknowledges that the Veteran is competent to testify as to his observations, Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006), and lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 131, 1316 (Fed. Cir. 2009). (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). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). In this case, however, the question of whether the Veteran's bilateral shoulder and bilateral hand disorders are related to service is an etiological question unlike testimony as to a separated shoulder, varicose veins, or flat feet, which are capable of direct observation. See Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-309 (lay testimony is competent to establish the presence of varicose veins); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). Arthritis is not a condition that has been found to be capable of lay observation, and the determination as to the presence or diagnosis of such a disability therefore is medical in nature and competent medical evidence is needed to substantiate the claim. The record does not show, nor does the Veteran contend, that he or has specialized education, training, or experience that would qualify him to provide an opinion on this matter. Accordingly, the lay evidence of a relationship is entitled to limited or no probative value in this regard. See Bostain v. West, 11 Vet. App. 124, 127 (1998); See also Routen v. Brown, 10 Vet. App. 183, 186 (1997). Thus, the Board finds that service connection for bilateral hand and bilateral shoulder disorder is not warranted. Although the Veteran has current disabilities, service treatment records do not show that he sought treatment for bilateral hand and bilateral shoulder disorders due to an injury in service, and the evidence of record fails to demonstrate that they are related to his military service. In reaching a determination in this case, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claims for service connection. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). As there is no medical evidence favorable to claim, and as the Board has found the Veteran's lay statements on a nexus between an injury in service and post-service diagnosis not competent evidence, the preponderance of the evidence is against the claim, and the benefit of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable and the appeal must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). ORDER Service connection for bilateral hand and finger disabilities is denied. Service connection for bilateral shoulder disabilities is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs