Citation Nr: 1318970 Decision Date: 06/11/13 Archive Date: 06/21/13 DOCKET NO. 04-28 321A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for multiple joint disability other than the bilateral hips and knees, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from April 1972 to March 1974 and from September 1990 to May 1991. During the intervening period he served in the Reserve Component, from which he retired in 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an April 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida that in relevant part denied service connection for degenerative joint disease of multiple joints, claimed as joint pain. In April 2006 the Veteran testified in a hearing before the RO's Decision Review Officer (DRO), and in October 2007 he testified before the undersigned Veterans Law Judge in a hearing at the RO ("Travel Board" hearing). Transcripts of both hearings are associated with the claims file. In November 2010 the Board reopened the previously denied claim for service connection for degenerative joint disease of multiple joints, and remanded the claim for additional development. In June 2012 the Board issued a decision denying service connection for degenerative joint disease of the bilateral hips and knees. The Board's action recharacterized the remaining issue on appeal as a claim for service connection for a multiple joint disability other than the bilateral hips and knees, to include as due to undiagnosed illness. The Board's action remanded that issue to the Appeals Management Center (AMC) for further development, which has been accomplished. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War. 2. The Veteran is service-connected for chronic fatigue syndrome; he does not have any other chronic disability, to specifically include a disability of the joints, that is etiologically related to an undiagnosed illness or a medically unexplained multisymptom illness. 3. The Veteran is diagnosed with degenerative joint disease of the cervical spine and the bilateral ankles, elbows, shoulders and wrists; he is also diagnosed with degenerative joint disease, degenerative disc disease and sciatica of the thoracolumbar spine. 4. Arthritis is not shown to have been present in any joint during service or to a compensable degree during the first year after discharge from service. 5. Competent and uncontroverted medical opinion states that the Veteran's disorders of the thoracolumbar spine, cervical spine, and bilateral wrists, elbows, ankles and shoulders are not due to or related to service, to include an undiagnosed illness. CONCLUSION OF LAW The requirements for establishing service connection for a multiple joint disability other than the bilateral knees and hips have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.30, 33.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Before addressing the merits of the Veteran's claim on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, the Veteran was provided notice in letters dated in June 2002, May 2006 and July 2008, regarding what information and evidence is needed to substantiate his claim, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The 2006 and 2008 letter advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. The case was last adjudicated in January 2013. In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009 (reversing prior cases law imposing a presumption of prejudice on any notice deficiency and clarifying that the burden of showing harmful or prejudicial error normally falls on the party attacking the agency's determination). See also Mayfield, 444 F.3d 1328, 1333-34. The record also reflects that service treatment records (STRs), service personnel records and all available post-service medical evidence identified by the Veteran have been obtained. In regard to STRs, the file contains STRs relating to both periods of active duty (April 1972 to March 1974 in the Marine Corps and September 1990 to May 1991 in the Army), but based on the Veteran's contention that further STRs must be missing the RO has made extensive efforts to find any records not already associated with the file; these efforts are memorialized in a Formal Finding of Unavailability of Service Medical Records dated in September 2006. The Veteran has been afforded appropriate medical examinations in regard to the claims on appeal. In June 2012 the Board remanded the file for additional VA examination, which was performed in July 2012. The Board has reviewed the examination report and finds the RO substantially complied with the requirements articulated in the Board's remand. See D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran was afforded a hearing before a Veterans Law Judge (VLJ) and a Decision Review Officer (DRO). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires the hearing officer who chairs a hearing explain the issues and suggest the submission of evidence that may have been overlooked. Here, both the DRO and the VLJ identified the issues to the claimant and asked specific questions directed at identifying whether the Veteran met the criteria for service connection. Additionally, the Veteran volunteered his treatment history and symptoms during and since service. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the DRO or Board hearing. The hearings focused on the elements necessary to substantiate the claims, and the Veteran provided testimony relevant to those elements. As such, the Board finds that there is no prejudice in deciding the claim at this time and no further action pursuant to Bryant is necessary. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield, 499 F.3d 1317. Therefore, the Board finds that duties to notify and assist have been satisfied and will proceed to the merits of the issue on appeal Applicable Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted on a presumptive basis for arthritis that became manifest to a compensable degree within the first year after discharge from service, even if not documented during service. 38 C.F.R. §§ 3.307, 3.309(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Because the Veteran served in the Southwest Asia Theater of operations since August 2, 1990, service connection may also be established under 38 C.F.R. § 3.317. Under 38 C.F.R. § 3.317, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War. For a disability due to undiagnosed illness and medically unexplained chronic multisymptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2016. See 76 Fed. Reg. 81834 (Dec. 29, 2011) (codified at 38 C.F.R. § 3.317(a)(1)). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. at 8-9. A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A "medically unexplained chronic multisymptom illness" contemplates a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). For purposes of 38 C.F.R. § 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Evidence and Analysis Service treatment records (STRs) relating to the Veteran's first period of active service (1972-1974) show no indication of traumatic injury to the joints or any abnormality of any joints during separation examination. STRs relating to the Veteran's second period of active service (1990-1991) show no complaint of joint pain or injury. The Veteran had a separation examination in April 1991 in which his self-reported Report of Medical History denied a history of recurrent back pain, lameness, arthritis/rheumatism/bursitis, neuritis, "trick" or locked knee, painful or "trick" shoulder or elbow or deformity of the bones or joints. The corresponding Report of Medical Examination showed "normal" evaluation of the spine, joints and other musculoskeletal systems. The Veteran was discharged from active service in May 1991. In July 1991 the Veteran presented to Dr. Keith Brady complaining of having injured his left ankle while playing basketball earlier that month. X-ray showed a chip fracture of the ankle. The Veteran had a VA general medical examination in October 1992 in which he complained of cervical and low back ache, aching knees and aching elbows for the past two years, described as intermittent and lasting one to two days. Examination of the musculoskeletal system and nervous system was grossly normal; X-ray of the lumbosacral spine showed minimal hypertrophic changes and normal alignment. The examiner diagnosed cervical arthritis and low backache. The Veteran received VA treatment in November 1992 for complaint of low back pain radiating to the right hip and knee, reportedly for several days. X-rays of the lumbosacral spine, bilateral hips and right knee were all normal. The RO issued a rating decision in March 1993 that denied service connection for backache/joint aches and left ankle injury. The Veteran appealed, but as noted below the denial was subsequently affirmed by the Board. The Veteran had a Persian Gulf War examination in September 1993 in which he complained of multiple joint pains for the past 2.5 years, which he stated were in the upper and lower extremities. He denied swelling or redness in the joints but endorsed morning stiffness. Physical examination of the musculoskeletal and neurological systems was grossly normal, and no relevant diagnosis was recorded. The Veteran presented to Dr. Keith Brady in September 1993 complaining of aching joints since returning from the Persian Gulf, mainly in the metacarpophalangeal (MCP) joints and also in the toes, hip and neck. He complained to Dr. Keith that he had been seen from time to time by VA but nothing could be found. Dr. Keith performed an examination and found the neck, shoulders, elbows, hands, wrists, knees and feet to be completely normal. The clinical impression was "arthralgias." In April 1994 the Veteran had an "over 40" physical examination for the Reserve Component in which his self-reported Report of Medical Examination complained of "joint aches" and low back pain since returning from Southwest Asia. He specifically reported joint pains for about three years. However, in the corresponding Report of Medical Examination the spine, joints and other musculoskeletal systems were evaluated as "normal." The Veteran presented to Dr. Brady in July 1994 complaining of achy joints, but examination of the joints was unremarkable. The Veteran presented to the VA clinic in October 1994 complaining of intermittent low back pain for the past three years, with radiating pain into the right lower extremity (RLE). Magnetic resonance imaging (MRI) and X-ray analysis showed early spondylosis of the lumbar spine. The clinical impression was sciatica, for which the Veteran was again treated in July 1995. In November 1994 the Veteran presented to Dr. Brady complaining of pain and spasms in the shoulder, although the area he described extended well beyond the shoulder and into the area of the ribcage. Physical examination was grossly normal, with normal range of motion (ROM) but noted "mild discomfort." The clinical impression was shoulder pain, probably tendinitis. The Veteran presented to the VA clinic in August 1995 complaining of a four-year history of joint pain "all over" (all extremities). The clinical impression was fatigue, not likely due to an organic cause. The Veteran had a special VA neurological evaluation in January 1996 due to complaint of increasing fatigue accompanied by aches and pains. The Veteran was found to be neurologically intact, with no evidence of myopathy. The Veteran testified before the RO's Hearing Officer in December 1996 that he began having back problems in service while carrying heavy loads road marching; he also testified that he had onset of arthralgias of multiple joints in October 1990. When asked which specific joints were painful, the Veteran responded that basically all his joints were painful but specifically cited the hands, arms, legs, elbows, shoulders, knees, ankles, feet and neck. The Veteran stated he believed he had first been treated for such problems in October 1991, by VA. The file contains a statement by the Veteran's ex-wife, received in October 1997, stating the Veteran had no illnesses or complaints until he deployed to the Persian Gulf; since his return from the Persian Gulf the Veteran had exhibited a constellation of problems including complaints of back and joint pain. Similarly, the file contains a letter from Mr. AHB, also received in October 1997, that asserts something had happened to the Veteran health-wise in Southwest Asia, and that in Mr. AHB's opinion the Veteran is a "bona fide candidate" for disabilities including arthritis. The file contains a VA outpatient note dated in April 1999 in which the Veteran complained of symptoms since 1991, including generalized arthralgias. The Veteran described the arthralgias as intermittent, sometimes agonizing, and affecting primarily his right hip, neck, fingers and elbows. All previous workups had been negative. Extensive clinical examination was essentially normal. The physician entered an assessment of arthralgias, examination normal, with plan for follow-up by a rheumatologist. The Veteran thereafter had a VA rheumatology clinic consult in April 1999 to follow up complaints including arthralgias in the back, neck and hands, reportedly of 7 years duration. Clinical examination was grossly normal, with no joint swelling. The impression was arthralgias of no clear etiology but may be related to chronic pain and underlying adjustment disorder with depressed mood. The clinical note observed there was nothing to suggest inflammatory arthropathy or inflammatory myositis. The Board issued a decision in December 1999 denying service connection for multiple joints arthralgia, based on a determination that the Veteran's claimed multiple joint pain had been attributed to clinically-diagnosed arthralgia but there was no competent medical evidence showing a nexus between arthralgia and active service. The Board's action also denied service connection for a lumbosacral spine disorder based on a determination that the was no competent medical evidence showing a nexus between a lumbosacral spine disorder, to include lumbar disc prolapse at L5-S1 and degenerative changes, and the Veteran's active service. In May 2000 the Veteran was referred by Dr. Keith to Dr. Susan Fraser for evaluation of pain in multiple joints. The Veteran asserted his belief that his symptoms were due to participation in the Persian Gulf War. The Veteran voiced a number of health complaints, but his chief complaint was pain in all joints, intermittent and sometimes absent for a week at a time but then recurring. The pain was accompanied by fatigue and muscle pain. The Veteran denied joint swelling. Dr. Fraser performed a full physical examination and noted observations in detail. Dr. Fraser's impression was polyarthralgias; arthritis of the knees and elbows of uncertain cause; and, generalized myalgias with no definite fibromyalgia diagnosed on current examination. The Veteran returned to Dr. Fraser in July 2000 complaining of continued pain in multiple muscles and joints. He again denied joint swelling. Dr. Fraser performed an examination and noted observations in detail. Her impression was inflammatory arthritis, either seronegative rheumatoid arthritis or spondyloarthropathy although he did not quite meet the criteria for the latter. The Veteran presented to the VA outpatient clinic in September 2000 with the same chronic complaints. Physical and neurological examination was essentially normal, and the clinician entered an impression of arthralgias of unclear etiology. He again presented to the outpatient clinic in January 2001 complaining of the same symptoms, and the clinician agreed to once again refer the Veteran to the rheumatology clinic. Thereafter, the Veteran presented to the VA rheumatology clinic for consultation in January 2001. Once again there was no indication of a rheumatologic disorder; the clinical impression was arthralgia of undetermined origin. In April 2001 the Veteran had a consult to the VA physical medicine and rehabilitation (PMR) clinic, where he was noted to have a history of depression and adjustment disorder as well as complaints of generalized pain for approximately 10 years. Clinical examination of the joints was normal, with no deformity, effusion, laxity or pain. There were no fibromyalgia tender spots, and neurological examination was also grossly normal. The physician stated that from history and physical examination the Veteran had no focal neural or muscular problems that could be identified, and the physician questioned whether the Veteran's fatigue and pain syndrome may be related to his psychiatric etiology. The Veteran presented to the VA emergency room in December 2001 complaining of pain in the right leg and right shoulder, originating in the lumbar and cervical areas. X-ray of the lumbar spine showed minimal DJD characterized by spur formation and narrowing of the posterior L5-S1 interspace, while X-ray of the cervical spine showed minimal degenerative joint disease DJD characterized by anterior bridging of C4 and C5 and narrowing of the corresponding lower interspaces. The Veteran had a VA rheumatology consult in February 2002 to follow up his complaints of arthralgias of undetermined etiology. The Veteran complained of bouts of arthralgia ever since returning from the Persian Gulf, with attacks usually lasting about 2 weeks. Previous rheumatology diagnostics had not shown significant abnormalities. The Veteran related the pain to his limbs, but he could not really discriminate between muscle versus joint pain. Neurological examination was grossly normal. The clinical impression was myalgia or arthralgia not otherwise specified (NOS) of undetermined etiology. The Veteran had a VA bone scan in July 2002 due to complaint of diffuse intermittent pain, mostly in the lower extremities. The impression was normal bone scan. A VA rheumatologist entered a note in June 2006 recording the Veteran's complaint of pain in the lower extremities, intermittent and acute and unaccompanied by any joint or extremity swelling. The rheumatologist stated he was at a loss to explain the Veteran's symptoms, but was concerned about the supra-tentorial elements to his problem. The rheumatologist stated an intention to pursue via bone scan. The file contains a "buddy statement" from RLC received in July 2002. RLC stated that prior to Desert Storm the Veteran did very well on the Annual Physical Fitness Test (APFT), especially the run, but after returning from Southwest Asia the Veteran began to complain of joint pains; the Veteran began walking the APFT instead of running and sometimes failed the APFR altogether. The Veteran's ex-wife sent a letter to VA in August 2002 again asserting that the Veteran had no health problems prior to Desert Storm; after his return from that operation she noticed he began to complain of symptoms including severe back and joint pains. The Veteran had a VA orthopedic joints examination in December 2002, performed by a physician who reviewed the claims file. The Veteran denied significant trauma or injury to the joints other than minor ankle sprains which spontaneously resolved. However, he reported that since serving in Southwest Asia he had fatigability and joint pains, intermittent and vague in nature. His primary complaints were the knees, hips and ankles. The examiner performed a full orthopedic examination and noted observations in detail. X-rays showed moderate lumbar spondylosis, very minimal degenerative arthritis in the hips and knees and no significant osteoarthritis in the ankles. The examiner's assessment was multiple joint pain affecting the knees, ankles and hips with flare-ups every two weeks. The examiner did not provide an opinion regarding the etiology of the symptoms. The Veteran also had a VA examination of the left ankle in December 2002, performed by a podiatrist who reviewed the claims file. The Veteran endorsed having had one or two ankle sprains. Examination of the ankle was unremarkable, and X-ray revealed no degenerative arthritis or other abnormalities. The examiner's diagnosis was normal examination of the ankle, without evidence of instability or degenerative arthritis. The Veteran had a VA rheumatology clinic follow-up in January 2003, noting history of arthralgias reportedly since the Veteran's return from the Persian Gulf. Attacks were episodic and accompanied by fatigue; previous extensive rheumatologic work-ups had been negative and X-rays of the back and neck had shown minimal DJD. Physical examination was unremarkable. The clinician's impression was that he had no good explanation for the Veteran's symptoms, which did not have typical tender points consistent with fibromyalgia. Also, workup and evaluation did not reveal a systemic rheumatologic condition. The Veteran was thereupon discharged from the rheumatology clinic. The Veteran presented to the VA outpatient clinic in July 2003 complaining of left shoulder pain. X-ray of the left shoulder was suggestive of localized DJD. The Veteran testified before the RO's Decision Review Officer (DRO) in April 2006 that prior to going to the Persian Gulf he had no arthritis or joint pain, but since returning from the Persian Gulf he had been treated with acupuncture, medication and physical therapy. In approximately 1990 he was injured practicing hand-to-hand combat, and was treated in service. The Veteran testified he had been diagnosed with DJD within a year of his discharge from active service, although to his knowledge he had never been diagnosed with arthritis. The Veteran had a VA Persian Gulf War Guidelines examination in July 2006, performed by an examiner who reviewed the claims file. The Veteran complained of pain in all his joints, large and small, described as intermittent and lasting up to a week. The pain would wax and wane due to unknown factors. Musculoskeletal examination of the joints was grossly normal, as was neurological examination. The examiner's diagnosis was joint pain due to osteoarthritis; the examiner stated there was no chronic pain syndrome. The examiner stated as rationale that X-rays showed arthritis but there was no evidence of any rheumatologic disease. The Veteran testified before the Board in October 2007 that he began having joint pains after he returned from the Persian Gulf, while he was still a member of the Reserve Component. He denied any joint pain or problems prior to service. He continued to be treated for pain in multiple joints, with joints identified as arthritic and other joints not having any diagnosis. The Veteran had a VA examination of the joints in March 2011, performed by a physician who reviewed the claims file. The examination focused exclusively on the Veteran's hips and knees, which the Veteran identified as the joints that caused him the most problem. The examiner diagnosed mild DJD of the bilateral hips and knees and stated an opinion that these disorders are not likely due to service, to include an undiagnosed illness. In June 2012 the Board issued a decision that denied service connection for hips and knees and remanded the question of service connection for joints other than the hips and knees for further development. The Veteran had a VA examination of multiple joints in July 2013, performed by a physician who reviewed the claims file. The Veteran denied problems with his ankles, elbows, shoulders, wrists, thoracolumbar spine or cervical spine prior to service, and he could not recall any specific ankle, shoulder or cervical spine injuries during or after service. The Veteran could not recall any specific acute back injuries during service but reported feeling tired and sore after lifting heavy loads during service. The Veteran could not recall any specific injuries to the elbows during service, but reported he sometimes had to sleep inside vehicles in awkward positions. The Veteran reported an injury to his left wrist during his first period of active duty, which subsequently healed. The examiner performed an examination of the ankles, elbows, thoracolumbar spine, cervical spine, shoulders, and wrists, and noted observations in detail. The examiner diagnosed DJD of the bilateral ankles, bilateral elbows, bilateral shoulders and bilateral wrists; DJD, degenerative disc disease (DDD) and sciatica of the thoracolumbar spine; and, DJD of the cervical spine. The examiner noted the Veteran was already service-connected for chronic fatigue syndrome as due to an undiagnosed illness and stated there were no other diagnosed illnesses for which an etiology had not been established. The examiner noted that review of the claims file showed the Veteran had been extensively worked up for his various musculoskeletal symptoms and conditions but no compelling evidence of a systemic rheumatologic disorder was found. The Veteran was shown to have DJD of multiple joints, which is a well-recognized clinical entity and does not fall into the realm of "undiagnosed illness." The examiner stated an opinion that the Veteran's widespread DJD is most likely related to the aging process, among several risk factors; there was no objective evidence in the current database demonstrating the Veteran's diffuse DJD was due to or the result of active service, to include service in the Persian Gulf area. Review of the file shows the Veteran is competently diagnosed with DJD of the bilateral ankles, bilateral elbows, bilateral shoulders and bilateral wrists and cervical spine; he is also diagnosed with DJD, DDD and sciatica of the thoracolumbar spine. Accordingly, the first element of service connection - medical evidence of a claimed disability - is met. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000). The Board notes at the outset that the Veteran is not shown to have had arthritis of any joint to any degree during service, or to a compensable degree during the first year after discharge from service. This is demonstrated by the fact that the earliest notation of degenerative arthritis occurs in December 2002 ("very minimal" degenerative arthritis in the hips and knees), after which a January 2003 treatment note recorded "minimal DJD" of the back and neck. These findings were recorded many years after the Veteran's discharge from active service in May 1991. The Board accordingly finds that presumptive service connection for arthritis under 38 C.F.R. § 3.309(a) is not warranted. Turning to direct service connection, the competent and uncontroverted medical opinion of record, in the form of the VA examination report in July 2013, states that the Veteran's current disorder of the thoracolumbar spine, cervical spine and bilateral shoulders, elbows, wrists and ankles are not etiologically related to service, to include an undiagnosed illness. The findings of a physician are medical conclusions that the Board cannot ignore or disregard. Willis v. Derwinski, 1 Vet. App. 66 (1991). In relying on the opinion of the VA examiner in July 2013, the Board specifically finds the examiner was demonstrably fully informed of the pertinent factual premises of the case and that he provided a fully articulated opinion that was supported by a reasoned analysis. The examination report accordingly fully comports with the criteria for probative value articulated in Nieves-Rodriguez, 22 Vet. App. 295, 303-304. The Board has considered the lay evidence offered by the Veteran, to include his testimony, the correspondence submitted to VA by the Veteran and various family members and acquaintances, and the Veteran's statements to various medical examiners and providers. A layperson is competent to report about factual matters about which he had firsthand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). The Veteran in this case has asserted his joint pain began during service, and he has provided lay witness statements attesting that he had no observable symptoms consistent with joint pain and weakness prior to service in the Persian Gulf but has had such symptoms thereafter. However, the Board notes that such contention is inconsistent with his Report of Medical History at separation from service wherein he denied any joint symptoms. Such inconsistency reduces the reliability and credibility of the information currently being provided. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-1337 (2006) (conflicting statements of the veteran are factors that the Board can consider and weigh against a veteran's lay evidence); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence). Moreover, the Board notes the Veteran was not shown to have arthritis in service or for many years thereafter. Thus, whether his alleged pain during service is in any way related to the current disability requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). To the extent the Veteran's lay evidence is intended to establish that he has a current joint disability that had its onset during service, neither the Veteran nor his correspondents are shown to have the medical expertise to render an opinion regarding a question as complex as the etiology of musculoskeletal symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Rather, it is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). As noted above, the competent and uncontroverted medical opinion of record states the Veteran's claimed disorders are not related to service. Such opinion is significantly more probative than the lay assertions concerning the etiology of the Veteran's current disability. Based on the evidence and analysis above the Board finds the Veteran does not have a multiple joint disability other than the bilateral hips and knees that is related to service, to include as due to an undiagnosed illness or a medically unexplained multisymptom illness. Accordingly, the criteria for service connection are not met and the claim must be denied. In making the determination above the Board has considered the benefit-of-the-doubt rule. When service records are not available, case law does not establish a higher benefit-of-the-doubt standard, but rather heightens the duty of the Board to consider the benefit-of-the-doubt rule, to assist the claimant in developing his claim, and to explain its decision; see Ussery v. Brown, 8 Vet. App. 64 (1995). The preponderance of the evidence in this case is against the claim, and the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. ORDER Service connection for a chronic multiple joint disability other than the bilateral hips and knees is denied. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs