Citation Nr: 1318858 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 08-35 000 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a right arm disability. 2. Entitlement to service connection for a left arm disability. REPRESENTATION Veteran represented by: Military Order of the Purple Heart of the U.S.A. WITNESS AT HEARINGS ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Becker, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1971 to May 1971. This matter comes before the Board of Veterans' Appeals (Board) from a May 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The previous denials of service connection for flexion contracture of the right elbow and of the left elbow were confirmed and continued therein. Upon the Veteran's appeal of these determinations, jurisdiction then was transferred to the RO in Chicago, Illinois. In March 2009, the Veteran testified regarding this matter at a Decision Review Officer hearing. He also testified regarding this matter before the undersigned Veterans Law Judge at a Travel Board hearing in April 2010. The Board determined in January 2011 that new and material evidence sufficient to reopen the previously denied service connection issues had been submitted. These issues were remanded for additional development at that time as well as in May 2012 and February 2013. Such development now has been completed or at least substantially completed. Adjudication thus may proceed, if otherwise in order. Dyment v. West, 13 Vet. App. 141 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002); Stegall v. West, 11 Vet. App. 268 (1998). No reason is found for delaying adjudication at this time. Accordingly, the following determinations are based on review of the Veteran's claims file in addition to his Virtual VA "eFolder." FINDINGS OF FACT 1. The Veteran does not have a current right arm disability at the shoulder or elbow. 2. The Veteran has a current left arm disability at the elbow but not at the shoulder, but there is clear and unmistakable evidence that he had such a disability prior to his service and that it was not aggravated during his service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right arm disability have not been met. 38 U.S.C.A. §§ 101, 1110, 1111, 1153, 5107 (West 2002); 38 C.F.R. §§ 3.2, 3.102, 3.303, 3.304, 3.306, 3.310 (2012). 2. The criteria for entitlement to service connection for a left arm disability have not been met. 38 U.S.C.A. §§ 101, 1110, 1111, 1153, 5107 (West 2002); 38 C.F.R. §§ 3.2, 3.102, 3.303, 3.304, 3.306 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Before addressing the merits, VA has a duty to notify claimants. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159. VA must notify the claimant and his representative, if any, prior to the initial decision by the agency of original jurisdiction (AOJ) of any information and any evidence not of record that is necessary to substantiate the claim, that VA will seek to obtain, and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Notification that an evaluation and effective date will be assigned if the benefit sought is granted also must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found. Via letter dated in October 2006, which was resent in December 2006 pursuant to the Veteran's request, he was notified of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines evaluations and effective dates for disabilities that are service-connected. This was prior to appointment of his representative as well as prior to the initial adjudication by the RO, which in this case also is the AOJ, in the May 2007 rating decision. Although nothing more was required, a subsequent September 2007 letter sent to the Veteran and his newly appointed representative readdressed how VA determines evaluations and effective dates for disabilities that are service-connected. In addition to the duty to notify, VA has a duty to assist claimants. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). VA is required to aid the claimant in the procurement of relevant records. 38 U.S.C.A. § 5103A(b-c); 38 C.F.R. § 3.159(c)(1-3). VA also is required to provide a medical examination and/or obtain a medical opinion when necessary. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Veteran's service treatment records, VA treatment records, and Social Security Administration (SSA) records have been obtained by VA. Some of the VA treatment records were obtained pursuant to the Board's January 2011 remand, while the SSA records were obtained pursuant to the May 2012 remand. Identified pertinent private treatment records dated recently have been obtained through VA's efforts and the Veteran submitting them on his own behalf. Earlier pertinent private treatment records have been referenced by the Veteran. No such records were obtained, despite VA's efforts, during the pendency of his initial claim in 1978. In compliance with the January 2011 and February 2013 remands, he was requested to identify them and authorize their release to VA. No response was received, and thus the records were not obtained. A Veteran cannot passively wait for help when he may or should have information essential to obtaining evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). As determined in the Board's January 2011 remand, an April 2009 VA medical opinion is inadequate. A VA medical examination was conducted and another VA medical opinion rendered in February 2011 pursuant to this remand. In compliance with the May 2012 remand finding this second opinion inadequate, a supplemental VA medical opinion was rendered in June 2012. With these actions, the determinations herein are fully informed. The examination and last opinion therefore are adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Neither the Veteran nor his representative has identified any additional action necessary for fair adjudication that has not been completed. The record also does not indicate any such action. Therefore, the Board finds that no further notice or assistance is required and that VA's duties to notify and to assist have been satisfied. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio, 16 Vet. App. at 183. Adjudication thus may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). II. Service Connection The Veteran contends that he either incurred or aggravated a left arm disability during service. He contends the same for a right arm disability. Specifically, he primarily recounts that having problems ever since doing push-ups and carrying heavy duffel bags during service. The Veteran alternatively contends that he has a right arm disability because of the left arm disability, in that it forced him to use the right arm more over the years. Service connection means the facts, shown by evidence, establish that an injury or disease resulting in disability was incurred in service, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a); 38 U.S.C.A. § 1110. To establish service connection, there generally must be a current disability, the in-service incurrence or aggravation of an injury or disease, and a nexus between the current disability and the in-service injury or disease. Hickson v. West, 12 Vet. App. 247 (1999); Barr, 21 Vet. App. at 303. Service connection also may be established for any disease diagnosed after discharge when the evidence shows it was incurred in service. 38 C.F.R. § 3.303(d). For chronic diseases, service connection additionally may be established through chronicity or continuity of symptomatology. 38 U.S.C.A. § 1101(3); 38 C.F.R. §§ 3.303(b), 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Savage v. Gober, 10 Vet. App. 488 (1997). Service connection further is presumed for chronic diseases if certain requirements are met. 38 U.S.C.A. §§ 1112, 1113, 1153; 38 C.F.R. §§ 3.307, 3.309(a). Secondary service connection means that a nonservice-connected disability is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). To establish service connection on a secondary basis, a current disability must be caused or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). With respect to aggravation, the baseline level of disability pre-aggravation must be compared to the current level of disability. 38 C.F.R. § 3.310(b). Compensated is given only for the degree of disability over and above the baseline plus natural progression. Id.; Allen, 7 Vet. App. at 439. The Board must identify the evidence it finds to be persuasive and unpersuasive and explain why any favorable evidence is unpersuasive. Gabrielson v. Brown, 7 Vet. App. 36 (1994); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, an assessment of the probative value of the lay evidence in addition to the medical evidence is required. A lay person is competent to relate observation or that which is within his personal knowledge. Layno v. Brown, 6. Vet. App. 465 (1994). Competent lay testimony or statements may be discounted in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). Credibility factors therefore include interest, self-interest, bias, inconsistency, facial implausibility, bad character, malingering, desire for monetary gain, and witness demeanor. Pond v. West, 12 Vet. App. 341 (1999); Macarubbo v. Gober, 10 Vet. App. 388 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995); Cartright v. Derwinski, 2 Vet. App. 24 (1991). "[T]he Board cannot determine that lay testimony or a lay statement lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, the lack of such evidence along with other factors may lead to the determination that the testimony or statement is not credible. When there is an approximate balance of positive and negative medical and lay evidence, reasonable doubt is resolved in favor of the Veteran. The Veteran thus prevails when the evidence supports his claim or is in relative equipoise but does not prevail when the preponderance of the evidence is against his claim. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. Although all the evidence has been reviewed, only the most salient and relevant evidence is discussed below. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). The Board finds that service connection for a right arm disorder and for a left arm disorder is not warranted. It follows from the above that there can be no valid claim if there is no current disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). A current disability exists when there is a disability at the time a claim is filed or at any time during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The Veteran filed his claim in September 2006. Whether or not he asserts having a bilateral elbow disability or a bilateral shoulder disability is unclear. He indeed did not respond to a February 2013 letter requesting clarification in this regard pursuant to the Board's remand that month. Both the elbows and the shoulders therefore shall be considered. Only the left arm and elbow specifically were mentioned by the Veteran's VA treating physician since April 2007 in a March 2009 letter. No diagnosis was made. The physician indeed indicated no prior awareness of a left arm or elbow problem. A current left elbow disability exists, however. While neither VA treatment records, private treatment records, nor SSA records contain such a diagnosis, the Veteran was diagnosed with severe left elbow flexion contracture at the February 2011 VA examination. He, in contrast, does not have a current right elbow disability, right shoulder disability, or left shoulder disability. No diagnosis of such was made in VA or private treatment records or in SSA records. None was made at the aforementioned examination. In June 2012, the VA examiner instead noted with respect to the Veteran's right elbow that it had been essentially without disability upon examination. The only significant finding, a lack of 10 degrees of extension, indeed was characterized as a normal variant. Although the April 2009 VA opinion referenced "flexion contractures," which implicates the right as well as the left elbow, the discussion below reveals that the opinion relates to the past. The physician who rendered this opinion further did not perform a physical assessment of the Veteran as did the VA examiner. Since there is no indication that the Veteran has medical expertise, he is a lay person. A lay person is competent to diagnose a disability when the lay person is competent to identify it, the lay person is reporting a contemporaneous medical diagnosis, or lay testimony describing symptoms supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Conditions such as flat feet, a dislocated shoulder, certain skin ailments, tinnitus, and varicose veins are examples of disabilities a lay person is competent to identify. Jandreau, 492 F.3d at 1372; Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Charles v. Principi, 16 Vet. App. 370 (2002); Falzone v. Brown, 8 Vet. App. 398 (1995). A right or left shoulder disability or a right elbow disability, other than dislocation or a broken bone, is not a condition a lay person such as the Veteran is competent to identify. There are numerous possible such disabilities, many of which have similar or the same rather than distinct symptoms. The Veteran has not reported a contemporaneous medical diagnosis. Indeed, this is impossible given that there are no diagnoses regarding the shoulders or right elbow. The Veteran finally has not described symptoms supporting a later medical diagnosis concerning the shoulders or right elbow. He has reported pain overall, weakness in the left arm, and limited extension of the right elbow. He is competent in this regard because he would personally experience such symptoms, and he is credible because there is no reason for doubt. Of note indeed is that some of his left side symptoms have been attributed to a June 2008 cerebrovascular accident, which his representative seemingly contends is related to service. Yet symptoms do not constitute a disability until attributed to an underlying diagnosis. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). It is reiterated that no diagnosis has been made despite the Veteran's symptoms. In sum, the Veteran has a left arm disability at the elbow but not the shoulder while he does not have a right arm disability at the elbow or the shoulder. No further discussion of the shoulders or right elbow thus is necessary. This includes secondary service connection for the right shoulder and elbow. With respect to the left elbow, flexion contracture is not a chronic disease. Chronicity, continuity of symptomatology, and presumptive service connection thus need not be discussed. That leaves regular service connection. The Veteran manifested a left elbow problem during service. Service treatment records document that he complained of left elbow pain 4 days after his induction in April 1971. It subsequently was noted that he could not fully extend his left arm, as there was a slight decrease in extension at the elbow. Flexion contracture ultimately was diagnosed. In-service manifestation necessitates consideration of the presumption of soundness. Gilbert v. Shinseki, 26 Vet. App. 48 (2012). A Veteran will be presumed to have been in sound condition when examined, accepted, and enrolled for service except as to defects, infirmities, or disorders noted at that time. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). A history of preservice existence of a defect, infirmity, or disorder recorded at the time of examination does not constitute a notation of it. 38 C.F.R. § 3.304(b)(1). The Veteran's report of swollen or painful joints, specifically that his left elbow swells on exertion, prior to his entry to service in September 1970 thus is insufficient. Noted means only such defects, infirmities, or disorders as are recorded in examination reports. 38 C.F.R. § 3.304(b). Upon his entrance examination, which was conducted the same day, the Veteran's left upper extremity was normal. His PULHES profile indeed included a rating of 1 for the upper extremities, indicating a high level of fitness. Odiorne v. Principi, 3 Vet. App. 456 (1992). The presumption of soundness accordingly applies. However, it is rebutted where clear and unmistakable (obvious and manifest) evidence demonstrates that an injury or disease existed prior to examination and acceptance into service and was not aggravated by service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Clear and unmistakable evidence is an onerous evidentiary standard requiring that the conclusion be undebatable. Cotant v. Principi, 17 Vet. App. 116 (2003); Vanerson v. West, 12 Vet. App. 254 (1999). The lay evidence, medical evidence, medical principles, and medical judgment shall be considered. 38 C.F.R. § 3.304(b). There is clear and unmistakable evidence that the Veteran had a left elbow injury and/or disease prior to his September 1970 entrance examination. He reported being treated for a left elbow condition in the 1960's when he filed his initial claim in 1978. For the instant claim, he reported involvement in a motor vehicle accident (MVA) in June 1970 which required casting of his left arm to include the elbow. These reports are competent and credible for the same reasons as above. The MVA indeed is facially plausible and consistently has been reported. Nothing from the Veteran's demeanor at the Travel Board hearing in testifying concerning it conveyed dishonesty. A preservice injury from a MVA further is consistent with service treatment records. They show that the Veteran reported fracturing his left arm, apparently at the elbow, due to a MVA about 2.5 years prior even during service. While the timing of the MVA was recounted differently by the Veteran then and with respect to the instant claim, what matters is that he always has recounted it occurring prior to service. An April 1971 service treatment record further shows that his left elbow flexion contracture was determined to be attributable to an old trauma. A Medical Board specifically determined it to have existed prior to his entry into service as a result of an old accident. Finally, the VA examiner came to the same conclusion. Such undoubtedly involved consideration of medical principles, and the agreement between medical professional who drafted the service treatment record, the Medical Board, and the VA examiner bolsters confidence in their medical judgment. Notwithstanding the aforementioned, the Veteran has reported with respect to the instant claim that his left elbow essentially had healed prior to service. He is competent to so report for the same reason as above. Yet he is not credible. A normal left elbow prior to service is inconsistent with the Veteran's report in September 1970 that it swells on exertion. This report has more probative value than the Veteran's recent reports for two reasons. First, it was made contemporaneous to the preservice timeframe whereas the recent reports were made 35 or more years later. Rucker v. Brown, 10 Vet. App. 67 (1997); Curry v. Brown, 7 Vet. App. 59 (1994). Second, the Veteran arguably had an interest in reporting a left elbow prior to his acceptance into service. He was a draftee in the Vietnam era. 38 U.S.C.A. § 101(29); 38 C.F.R. § 3.2(f). A disqualifying health problem, whether or the left elbow or otherwise, thus would have equated with rejection from service and no obligation to fight in the Republic of Vietnam. Now it is in the Veteran's interest to report not having a health problem prior to service. Such a determination would mean that this matter is one of incurrence, which arguably is easier to prove, rather than aggravation. Financial compensation in the form of service connection benefits would be more likely, in other words. A normal left elbow prior to service also is inconsistent with the service treatment records to include those from the Medical Board. It is reiterated that they deemed the left elbow flexion contracture to have been present before service due to old trauma or an old accident. A preexisting injury or disease will be presumed to have been aggravated by service when there is an increase in disability during service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). An increase occurs when there is a lasting worsening of the injury or disease rather than temporary symptom flare-ups. Routen v. Brown, 10 Vet. App. 183 (1997); Beverly v. Brown, 9 Vet. App. 402 (1996); Jensen v. Brown, 4 Vet. App. 304 (1993); Green v. Derwinski, 1 Vet. App. 320 (1991); Hunt v. Derwinski, 1 Vet. App. 292 (1991). The aforementioned presumption is rebutted by clear and unmistakable evidence that the increase during service is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). VA bears the burden to rebut the presumption. Laposky v. Brown, 4 Vet. App. 331 (1993); Akins v. Derwinski, 1 Vet. App. 228 (1991). Insufficient evidence of aggravation does not meet the burden, only affirmative evidence proving that there was no aggravation does. Horn v. Shinseki, 25 Vet. App. 231 (2012). There is clear and unmistakable evidence that the Veteran's preexisting left elbow injury was not aggravated during service. A Medical Board determination to this effect, if conclusory, is not sufficient. Id. The Medical Board's unexplained determination to this effect here accordingly is noted only in passing. The presumption of aggravation does not apply because there was no increase in disability during service. It was determined above that the Veteran had left elbow flexion contracture prior to his service. Discussed above was that service treatment records document that he had the same by at least 4 days into his service. As such, a temporary or intermittent condition is not found. Service treatment records reflect only a slight decrease in left elbow extension and no obvious deformity, however. This belies any lasting worsening even though the exact extent of the flexion contracture prior to service is unknown because no treatment records dated then are available. Acknowledgement is given to the fact that the Veteran ultimately was given a permanent PULHES profile including a rating of 3 for the upper extremities, indicating a significant limitation, in April 1971. Odiorne, 3 Vet. App. at 456. This could be construed as suggesting an increase in disability over the rating of 1 he initially received. However, the above discussion supports that the rating of 1 was in error and that a rating of 3 should have been received initially. The Veteran likely was accepted into service when he should not have been as he contends, in other words. Of further note, there are four medical opinions regarding whether or not the Veteran's preexisting left elbow flexion contracture was aggravated beyond normal progression during service. Factors in assessing the probative value of a medical opinion include access to the claims file, the thoroughness and detail of the opinion, the accuracy of the factual premise underlying the opinion, the scope of examination, the rationale for the opinion offered, the degree of certainty provided, and the qualifications and expertise of the examiner. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Prejean v. West, 13 Vet. App. 444 (2000); Black v. Brown, 10 Vet. App. 297 (1997); Ardison v. Brown, 6 Vet. App. 405 (1994); Sklar v. Brown, 5 Vet. App. 140 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); Guerrieri v. Brown, 4 Vet. App. 467 (1993). The Veteran's treating physician opined that no determination could be made regarding whether or not the Veteran's preexisting left elbow flexion contracture was aggravated beyond normal progression during service. Lack of access to "the relevant medical records" was cited as the reason. Two opinions are inadequate, as referenced above. The April 2009 VA opinion that the Veteran's preexisting left elbow flexion contracture was not aggravated beyond normal progression by his service was found by the Board in its January 2011 remand to be inadequate because it was unsupported by a rationale. The VA examiner's February 2011 opinion that the Veteran's preexisting left elbow flexion contracture was not permanently worsened beyond its natural progression by service was found by the Board in its May 2012 remand to be inadequate because it was not based upon review of the claims file. The VA examiner's June 2012 opinion that it is not at least as likely as not that the Veteran's left elbow flexion contraction was aggravated beyond normal progression during service, in contrast, is adequate and of high probative value. The VA examiner is a physician. There is no indication that this examiner's interview and physical assessment of the Veteran, when conducted in February 2011, was not as thorough as needed. Review of the claims file was completed in June 2012. These actions ensured the accuracy of the factual premises underlying the opinion. It was expressed with certainty. A sufficiently detailed rationale was supplied in support of it. With respect to rationale, it is notable that the VA examiner's two opinions are the same. The only difference indeed is that the latter was rendered after review of the claims file whereas the former was not. This review did not alter the opinion, in other words. The rationale supplied for both opinions therefore is of import. The examiner indicated in February 2011 that carrying a duffel bag during service would not have caused any significant elbow contracture worsening. The Veteran's report of this event is competent, because it would have been personally experienced by him, and credible. Indeed, there is no significant reason for doubt. The examiner indicated in June 2012 that there is no clear evidence of any serious injury to the left elbow during service. This includes from carrying a duffel bag and otherwise. The only other event reported by the Veteran, being involved in a MVA during service, was not specifically noted. Yet this is of no consequence. The Veteran is competent to give his report for the same reason as above, but he is not credible due to inconsistency. He mentioned an in-service MVA only once, and service treatment records are silent for such. It finally is clear that the Veteran believes his preexisting left elbow flexion contracture was aggravated beyond natural progression by his service. A lay belief can sometimes be sufficient to prove nexus. Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau, 492 F.3d at 1372. However, the question of whether there is aggravation beyond natural progression in this case falls outside the province of a lay person. It rather is a medical question. Of import in this regard are the intricacies of lasting worsening and the complexities of the musculoskeletal system. Only those with specialized medical knowledge, training, and expertise are competent where the determinative issue is one of medical causation. Jones v. West, 12 Vet. App. 460 (1999). Therefore, the Veteran's aforementioned lay belief is not competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau, 492 F.3d at 1372. His credibility in this regard accordingly need not be addressed. The presumption, in sum, that the Veteran's left elbow was sound upon his entry into service has been rebutted. This matter accordingly is one of aggravation rather than incurrence of an injury or disease during service. Aggravation of left elbow flexion contracture was disproved above. As such, there cannot be a nexus between left elbow flexion contracture aggravated during service and the Veteran's current left arm disability at the elbow of flexion contracture. For each of the foregoing reasons, the preponderance of the evidence is against the Veteran's claim. The benefit of the doubt thus is inapplicable. Service connection for a right arm disability and for a left arm disability is denied. ORDER Service connection for a right arm disability is denied. Service connection for a left arm disability is denied. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs