Citation Nr: 1316616 Decision Date: 05/21/13 Archive Date: 05/29/13 DOCKET NO. 08-22 935A ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for a bilateral forearm disability. 2. Entitlement to service connection for a left hamstring disability. 3. Entitlement to service connection for posttraumatic stress disorder (PTSD). WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran served on active duty (AD) from September 1989 to March 1993. He also had additional service in the reserves, including active duty for training (ADT). This appeal to the Board of Veterans' Appeals (Board/BVA) is from an August 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In April 2009, as support for his claims, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge of the Board, who the Chairman had designated to preside over the hearing pursuant to 38 U.S.C.A. § 7107(c), (e)(2), and who resultantly is rendering the determination in this appeal. A transcript of the hearing is of record. The Board subsequently, in February 2011, remanded the claims for further development. The claim of entitlement to service connection for PTSD was remanded to provide the Veteran a statement of the case (SOC) concerning this claim pursuant to Manlincon v. West, 12 Vet. App. 238 (1999). That SOC was issued, and in response he filed a timely substantive appeal (VA Form 9) to complete the steps necessary to perfect his appeal of this additional claim to the Board, that is, in addition to the other claims he already had perfected an appeal concerning. See 38 C.F.R. § 20.200 (2012). He also had perfected appeals for service connection for back and neck disabilities, and the Board remanded these claims as well. However, in July 2012, so since, the RO granted service connection for cervical spine and lumbar strains. That represented a full grant of the benefits sought on appeal. Therefore, those claims are no longer before the Board, as a "case or controversy" involving a pending adverse determination that he has taken exception to no longer exists as regarding those claims. See Shoen v. Brown, 6 Vet. App. 456, 457 (1994) (quoting Waterhouse v. Principi, 3 Vet. App. 473 (1992)). If he does not agree with the 10 percent ratings and/or effective date of November 2, 2006, assigned for these disabilities, then he has to separately appeal these "downstream" issues. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (holding that where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement (NOD) thereafter must be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability and effective date). A portion of the Veteran's records are in the Virtual VA system. Instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide claims for benefits. Because this appeal was processed as part of the Virtual VA system, any future consideration of this appellant's claims should take into consideration the existence of this electronic record. The claim of entitlement to service connection for a left hamstring disability requires even more development, so the Board is again remanding this claim to the RO via the Appeals Management Center (AMC) in Washington, DC. Whereas the Board, instead, is going ahead and deciding the remaining claims of entitlement to service connection for a bilateral forearm disability and PTSD. FINDINGS OF FACT 1. The Veteran's bilateral forearm disability - namely, epicondylitis - is not shown to be etiologically related to his active military service. 2. However, PTSD has been diagnosed and attributed to a verified stressor during his service. CONCLUSIONS OF LAW 1. A bilateral forearm disability, including especially epicondylitis, was not incurred in or aggravated by the Veteran's active military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.6, 3.303 (2012). 2. But his PTSD was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 A. Full Grant of Benefits With respect to the Veteran's claim for service connection for PTSD, the Board is fully granting this claim. Consequently, the Board need not discuss whether there has been compliance with the duty-to-notify-and-assist obligations of the Veterans Claims Assistance Act (VCAA) because even if the Board was to assume, for the sake of argument, there has not been, this still would be inconsequential and, thus, ultimately amount to no more than nonprejudicial, i.e., harmless error. 38 C.F.R. § 20.1102. B. Duty to Notify As concerning the claim for service connection for a bilateral forearm disability, under the VCAA, when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, including apprising him of the information and evidence VA will obtain versus the information and evidence he is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). See also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). If, as here, the claim is for service connection, this notice should also include indication that a "downstream" disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Ideally, this notice should precede the initial adjudication of the claim. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). However, both the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) and the U. S. Court of Appeals for Veterans Claims (Court/CAVC) have clarified that, even when notice is not provided prior to initially adjudicating a claim or, if provided, was inadequate or incomplete, VA need only provide all necessary notice, give the Veteran opportunity to submit additional evidence and/or argument in response, and then readjudicate the claim, including in an SOC or supplemental SOC (SSOC), such that the essential fairness of the adjudication, as a whole, is unaffected because the appellant is still provided a meaningful opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV) (holding that an SOC or SSOC can constitute a "readjudication decision" that complies with all applicable due process and notification requirements if adequate VCAA notice is provided prior to the SOC or SSOC). As a matter of law, the provision of adequate VCAA notice prior to a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. See also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In Shinseki v. Sanders, 129 S. Ct. 1696 (2009), the U. S. Supreme Court made clear that VCAA notice errors, even when shown to have occurred, are not presumptively prejudicial, instead, must be judged on an individual case-by-case basis. Moreover, as the pleading party attacking the agency's decision, the Veteran, not VA, has this burden of proof of not only establishing error but also, above and beyond that, of showing how it is unduly prejudicial, meaning outcome determinative of his claim. Here, prior to the initial adjudication of the Veteran's claim, so in the preferred sequence, a letter was sent to him in February 2007 in accordance with the duty to notify provisions of the VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). He was notified of the evidence needed to substantiate his claim, of the information and evidence that VA would obtain, and of the information and evidence he was expected to provide, and informed that VA would assist him in obtaining supporting evidence, but that it was his ultimate responsibility to provide VA with any evidence pertaining to his claim. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). He also was notified of the criteria for establishing a "downstream" disability rating and effective date. See Dingess. Therefore, he has received all required notice concerning this claim. C. Duty to Assist VA also has a duty to assist the Veteran in fully developing his claim, including by obtaining all potentially relevant records and having him examined for a medical opinion when needed to fairly decide the claim. To this end, his service treatment records (STRs), service personnel records (SPRs), VA treatment records, private treatment records, lay statements, and the transcript of his hearing have been obtained and associated with the claims file for consideration. He also was provided a VA examination for his bilateral forearm disability. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examination obtained is adequate as it was predicated on a review of the claims file, contains a description of the history of the disability at issue, documents and considers the relevant medical facts and principles, and provides an opinion regarding the etiology of the Veteran's bilateral forearm condition. So VA's duty to assist by obtaining a VA examination and opinion concerning this claim has been met. 38 U.S.C.A. § 5103(A)(d)(2); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Regarding his videoconference hearing before the Board, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the Decision Review Officer (DRO) or Veterans Law Judge (VLJ) chairing a hearing fulfill two duties to comply with this VA regulation. These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked that may be advantageous to the claimant's position. Here, during the April 2009 hearing the presiding VLJ noted the basic requirements for establishing entitlement to service connection for a claimed disability and sought to identify any pertinent evidence not then currently in the file that might have been overlooked or was outstanding and that might tend to substantiate the claim. Moreover, the Veteran has not asserted that VA failed to comply with § 3.103(c)(2) or identified any prejudice in the conducting of that hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim and the Veteran, through his testimony, evidenced his actual knowledge of the elements necessary to substantiate his claim for benefits. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative demonstrating an awareness of what is necessary to substantiate a claim). As such, the Board finds that, consistent with Bryant, the presiding VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. As already alluded to, the Board remanded this claim in February 2011 to obtain records concerning the Veteran's periods of AD and ADT and to provide him a VA examination for a medical nexus opinion. His complete personnel records were obtained, and he was afforded a VA examination for his bilateral forearm disability. The February 2011 remand directives therefore have been completed. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Court or the Board confers on the Veteran or other claimant, as a matter of law, the right to compliance with the remand orders); but see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand not required under Stegall where there was substantial compliance with remand directives). VA has provided the Veteran opportunity to submit evidence and argument in support of his claim. He has not made the Board aware of any additional evidence needing to be obtained prior to appellate review, and no further action must be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Service Connection A. Applicable Law In order to establish entitlement to service connection for a claimed disability, the facts must demonstrate that a disease or an injury resulting in current disability was incurred in active military service or, if pre-existing active service, was aggravated therein, meaning worsened beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Service connection may be granted for any disease diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). In addition, certain chronic diseases, including arthritis, may be presumed to have been incurred during service if they become disabling to a compensable degree - generally meaning to at least 10-percent disabling - within one year of separation from service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309(a) (2012). For a 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. If the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). However, service connection based on a theory of continuity of symptomatology following service is applicable only to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Active military, naval, or air service includes not only AD but also any period of ADT during which the individual concerned was disabled or died from a disease or an injury incurred in or aggravated in the line of duty, or any period of inactive duty training (IADT) during which the individual concerned was disabled or died from an injury - though not also disease - incurred in or aggravated in the line of duty, also when a cardiac arrest or cerebrovascular accident occurs during such training. 38 U.S.C.A. § 101(21), (24) (West 2002); 38 C.F.R. § 3.6(a), (d) (2012). Reserve and National Guard service generally means ADT and IADT. ADT is full-time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). Basically, this refers to the two weeks of annual training, sometimes referred to as "summer camp," that each Reservist or National Guardsman must perform each year. It can also refer to the Reservist's or Guardsman's initial period of training. IADT includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316 , 502, 503, 504, or 505. 38 U.S.C.A. § 101 (23); 38 C.F.R. § 3.6(d). Basically, this refers to the twelve four-hour weekend drills that each Reservist or National Guardsman must perform each year and is often referred to as "weekend warrior" training. These drills are deemed to be part-time training. So to establish status as a "Veteran" based upon a period of ADT, a claimant must establish that he was disabled from disease or injury incurred or aggravated in the line of duty during that period of ADT. 38 C.F.R. § 3.1(a), (d); Harris v. West, 13 Vet. App. 509, 511 (2000); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). The fact that a claimant has established status as a "Veteran" for purposes of other periods of service (e.g., AD) does not obviate the need for him to establish that he is also a "Veteran" for purposes of the period of ADT where the claim for benefits is premised on that period of ADT. Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). Similarly, in order for a claimant to achieve "Veteran" status and be eligible for service connection for disability claimed during his inactive service, the record must establish that he was disabled from an injury, but not disease, incurred or aggravated during IADT. See Mercado- Martinez v. West, 11 Vet. App. 415, 419 (1998); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). Generally, an individual who has only Reserve or National Guard service (ADT or IADT with no AD) is not a Veteran as legally defined. In the service connection context, for example, this means the presumption of soundness upon entry into service and the presumptive service connection provisions of 38 C.F.R. § 3.307, applicable to AD, do not apply to ADT or IADT. The same is true of the presumption of aggravation. See Smith v. Shinseki, 24 Vet. App. 40 (2010); Biggins v. Derwinski, 1 Vet. App. 474, 476-78 (1991). Thus, service connection may be granted for a disability resulting from a disease or an injury incurred or aggravated while performing ADT, or from an injury incurred or aggravated while performing IADT. 38 U.S.C.A. §§ 101(24), 106, 1131 (West 2002). Establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). See also Caluza v. Brown, 7 Vet. App. 498 (1995). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is "credible", or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board must additionally determine whether such evidence is also credible). Only if the evidence is both competent and credible does it ultimately have probative value. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (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")); Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (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 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In ascertaining the competency of lay evidence, the Courts generally have held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found competent with regards to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). On the other hand, laypersons equally have been found not competent in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Competent medical evidence, as opposed to lay evidence, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza at 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see also Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). As fact finder, when considering whether lay evidence is satisfactory, the Board may not only consider internal inconsistency of statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, but also the Veteran's demeanor when testifying at a hearing when he has testified. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). See, too, Macarubbo v. Gober, 10 Vet. App. 388 (1997) (similarly holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons or bases 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). To this end, the Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit Court, citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id., at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court similarly has declared that, in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). B. Bilateral Forearm Disability STRs from the Veteran's period of AD do not reflect any complaints or diagnoses referable to his forearms, and he has not asserted that he sustained any injury during that period of service. Rather, he contends that he injured his forearms during an August 2006 incident in which he was thrown from a small boat during a training exercise. STRs from August 2006 confirm the occurrence of that incident. As alleged, he was ejected from the boat into the water. There was no loss of consciousness, acute onset of neck pain, or acute neurological symptoms. He reported he treaded water for about 45 seconds before being pulled back into the boat. After exiting the water, he reported neck pain and soreness and resultantly was put into a cervical spine collar as a precautionary protocol. A CT scan was normal, however, and he was discharged from the hospital the very next day. He was treated conservatively with Motrin for body soreness secondary to the blunt-force impact of his water entry, but there were no additional sensory or motor deficits. The records specifically noted the incident had occurred during a period of ADT. In November 2006, he reported experiencing aching in his forearms, but he denied any numbness or weakness. He said he had been gripping two ladder rails in the back of the boat at the time he was ejected, and that his forearms started aching the day after the incident. A notation from his VA physical therapist surmised the Veteran must have injured his forearms from gripping the rails and then being torn away. During his April 2009 videoconference hearing before the Board, the Veteran reiterated that he had been gripping some handrails at the time he was thrown from the boat into the water. He believed that had caused his current bilateral forearm condition. He had a VA compensation examination in June 2012 in response to this claim. Based on a review of the claims file, a history he provided, and the objective physical examination, the examiner diagnosed bilateral lateral epicondylitis. However, he concluded this condition was unrelated to the boating accident in service, as bilateral "tennis elbow" is more consistent with overuse-type activity, not trauma. There resultantly has not been the required attribution of the current epicondylitis to the injury in service in the boating accident. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). Indeed, to the contrary, the VA compensation examiner charged with making this necessary determination concluded unfavorably, disassociating this current disability from the boating trauma in service. So although the Veteran has this diagnosis of bilateral lateral epicondylitis, the overall weight of the evidence is against finding this condition was incurred during his service. There are two competent opinions addressing the etiology of his condition. According to the Court, "the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches." Guerrieri v. Brown, 4 Vet. App. 467, 470 (1993). The credibility and weight to be attached to these opinions is within the province of the Board. Id. The Veteran's VA physical therapist opined that the Veteran injured his forearms from gripping the rails on his boat and then being torn away and has consequent disability, presumably in the way of epicondylitis. Conversely, the VA examiner determined the Veteran's epicondylitis is instead due to overuse - not trauma, so not from that type of injury in service. The Board finds the VA examiner's opinion to be of greater probative value in this case. Not only did the VA examiner review the claims file for the pertinent history, including the specific records regarding the August 2006 incident, but he also diagnosed a specific condition as part of his opinion. And while review of the claims file is not necessarily determinative of an opinion's probative value, it does have significance if there is evidence in the file that might tend to affect the underlying basis or outcome of the opinion. Also, most of the probative value comes from its reasoning, not just from the conclusion ultimately reached. See, e.g., Neives-Rodriguez v. Peake, 22 Vet. App. 295 (2008). And in these critical respects the VA examiner's opinion is much more on point. In contrast, the physical therapist noted pain in the forearms but did not identify any particular diagnosis; the Board therefore is only left to presume the opinion was in reference to bilateral lateral epicondylitis. This is particularly relevant because the VA examiner's negative opinion is predicated upon the inherent nature of the diagnosed condition as not being traumatic in nature, so not the result of an injury, per se, rather, the consequence of repetitive-type motion over time. The therapist's opinion does not state specifically why epicondylitis is related to the incident in service and does not provide a different diagnosis upon which service connection could be granted. See Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001) (pain is not a compensable disability absent an underlying pathology). The Board also has considered the Veteran's own statements regarding the etiology of his condition. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific condition in this case, lateral epicondylitis, it falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Moreover, to the extent the Veteran has asserted continuous forearm symptomatology like pain, etc., since the August 2006 incident, lateral epicondylitis is not among the conditions listed as "chronic" in 38 C.F.R. § 3.309(a) and, therefore, cannot be shown as associated with service merely by showing continuity of symptomatology since. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). C. PTSD Service connection for PTSD, in particular, requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., meaning the diagnosis must be in accordance with the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV)); (2) a link, established by medical evidence, between current PTSD symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f) (2012). If VA determines that a Veteran engaged in combat with the enemy and that the alleged stressor is related to combat, then the Veteran's lay testimony or statements are accepted as conclusive evidence of the occurrence of the claimed stressor. 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(d) and (f)(2). No further development or corroborative evidence is required, provided the claimed stressor is "consistent with the circumstances, conditions, or hardships of the Veteran's service." Id. In this case, the Veteran's DD Form 214 does not reflect any engagement in combat against an enemy force, meaning his participation in an event constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. See VAOPGCPREC 12-99 (October 18, 1999). This determination is made on a case-by-case basis. See also Moran v. Peake, 525 F.3d 1157 (Fed. Cir. 2008). But effective July 13, 2010, so during the pendency of this appeal, VA amended its adjudication regulations governing claims for service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. See 75 Fed. Reg. 39843 (July 13, 2010). Specifically, the final rule amended 38 C.F.R. § 3.304(f) by redesignating current paragraphs (f)(3) and (f)(4) as paragraphs (f)(4) and (f)(5), respectively, and by adding a new paragraph (f)(3) that reads as follows: If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. The Veteran reports being involved in an incident during a training exercise in 1992. He was serving aboard the USS Saratoga when it accidentally fired upon a Turkish vessel. In various written statements and reports to his treating physicians, he stated that he "saw the whole thing," including a number of Turkish sailors wounded and killed. He was involved in the subsequent rescue and recovery operations, moving the wounded and dead onto his ship. He also submitted two statements from fellow servicemen corroborating his account of the unfortunate incident. A ship log history of the USS Saratoga submitted by the Veteran describes the incident in question, and his SPRs confirm he was stationed aboard the vessel at the time it occurred. Therefore, his claimed stressor has been verified. Moreover, VA treatment records from January 2007 reflect a diagnosis of PTSD by his treating physician following his recounting of that 1992 incident. As well, a brief November 2006 statement from his private physician specifically attributes the PTSD diagnosis to that stressor. There are no medical opinions or any other competent and credible evidence suggesting, much less indicating, the PTSD is attributable to some other cause unrelated to the Veteran's service. Therefore, the three requirements for establishing his entitlement to service connection for PTSD have been satisfied. His claim for this condition accordingly is being granted. ORDER The claim for service connection for a bilateral forearm disability is denied. But the claim for service connection for PTSD is granted. REMAND Still additional development is required in order to fully and fairly adjudicate the Veteran's remaining claim for service connection for a left hamstring disability. The Board previously remanded this claim in February 2011 for a VA examination and medical opinion. The Veteran had the requested examination in June 2012. The examiner reviewed the claims file, obtained a history from the Veteran, and performed a physical evaluation. He then diagnosed left hamstring strain but concluded it was not related to the August 2006 boating incident in service. No explanation was given to support this conclusion, however. The failure of that examiner to provide a basis for his opinion affects the weight or credibility of the opinion. Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). In addition, the examiner did not comment on STRs from September 1991 showing the Veteran had complaints of hip pain and listing a diagnosis of left thigh muscle strain. Therefore, a supplemental opinion is needed to address these deficiencies. See Nieves-Rodriguez, 22 Vet. App. at 304 (a medical opinion is not entitled to any weight if it contains only data and conclusions); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that, once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). And see Stefl v. Nicholson, 21 Vet. App. 120, \ 123-25 (2007) (VA's duty to assist includes providing an adequate examination when such an examination is indicated, and "a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to a doctor's opinion"); Miller v. West, 11 Vet. App. 345, 348 (1998) ("A bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record."); Dennis v. Nicholson, 21 Vet. pp. 18, 22 (2007) ("The Court has long held that merely listing evidence before stating a conclusion does not constitute an adequate statement of reasons and bases." (citing Abernathy v. Principi, 3 Vet. App. 461, 465 (1992)). Notably, service records from September 2004 document a left hamstring injury and indicate the Veteran was on "reserve" status at the time. However, his personnel records show that no AD or ADT was performed during the period in question. Moreover, there is no indication the injury was incurred in the line of duty. The Veteran also testified during his videoconference hearing before the Board that his hamstring injury was sustained during AD while running on a track, and that he was treated by Dr. R. The September 2004 records show the Veteran injured his hamstring while pursuing a criminal, and then reinjured it while climbing some stairs, and was treated by a Dr. M. Therefore, this evidence is against finding the injury in September 2004 occurred during a period of active military service. Nevertheless, this claim is again REMANDED for the following additional development and consideration: 1. The claims file, including a copy of this remand, should be forwarded to the VA examiner that evaluated the Veteran in June 2012 for hip and thigh conditions for submission of a supplemental opinion addressing the likelihood (very likely, as likely as not, or unlikely) the Veteran's current left hamstring strain is related or attributable to his military service or dates back to his service. The term "as likely as not" means at least 50-percent probability. It does not however mean merely within the realm of possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion such as causation is so evenly divided that it is as medically sound to find in favor of that conclusion as to find against it. In making this determination, the VA examiner must specifically address the findings from September 1991 showing a diagnosis left thigh muscle strain and from September 2004 showing a diagnosis of hamstring strain. Also, the examiner should again review records of the August 2006 boating incident. The examiner should provide a complete opinion, with supporting explanations, as to why the Veteran's current left hamstring strain is/is not related to the events in service. The current opinion does not provide any supporting rationale and does not consider all of the potentially relevant evidence, hence, the need for this additional comment. If an opinion cannot be provided without resorting to mere speculation, the examiner must state why this is the case. In other words, merely saying he cannot respond will not suffice. If, for whatever reason, the June 2012 VA examiner is unavailable to provide this further comment, then the claims file should be forwarded to someone else qualified to make this necessary determination. This new examiner should also specifically address the September 1991, September 2004, and August 2006 findings. This additional examiner also may want to examine the Veteran personally, rather than just review this evidence in the file, so it is left to his/her discretion as to whether another examination is needed. 2. Ensure this additional opinion is responsive to the questions posed. If not, take corrective action. 38 C.F.R. § 4.2 (2012). 3. Then readjudicate this remaining claim in light of this and all other additional evidence. If this claim continues to be denied, send the Veteran another SSOC and give him time to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of this remaining claim. The Veteran has the right to submit additional evidence and argument concerning this claim the Board is remanding. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs