Citation Nr: 1319155 Decision Date: 06/12/13 Archive Date: 06/21/13 DOCKET NO. 05-25 413 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for numbness of the back and legs and additional circulatory disorders. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The Veteran had active duty service from July 1977 to August 1983. This matter came to the Board of Veterans' Appeals (Board) from a January 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. This matter was remanded in October 2009, April 2011, and February 2013. FINDING OF FACT A disability manifested by numbness of the back and legs and additional circulatory disorders, to include degenerative arthritis of the lumbar spine, patellofemoral syndrome of the knees, and neuritis, was not manifested during the Veteran's period of active service, did not manifest within a year of separation from service, and current disabilities of the back and legs and additional circulatory disorders, to include degenerative arthritis of the lumbar spine, patellofemoral syndrome of the knees, and neuritis, are not otherwise the result of a disease or injury during active service. CONCLUSION OF LAW A disability manifested by numbness of the back and legs and additional circulatory disorders, to include degenerative arthritis of the lumbar spine, patellofemoral syndrome of the knees, and neuritis, were not incurred in or aggravated by active service; nor may they be presumed. 38 U.S.C.A. §§ 1101, 1112(a), 1131, 1137 (West 2002); 38 C.F.R. § 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent a letter in October 2004 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. In March 2006 he was informed of what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Contrary to VCAA requirements, some of the notice in this case was provided after the initial adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The timing deficiency was cured by readjudication of the claims in supplemental statements of the case, to include the most recent one in April 2013. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, to include substantial compliance with the Board remands. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The previous remands were for the purpose of affording the Veteran a VA examination information and obtain an adequate medical opinion. As will be discussed in detail below, the Veteran was afforded a VA examination in April 2010 and an addendum opinion was provided in May 2011. Due to a finding by the Board that this examination was insufficient, a VHA opinion was requested in August 2012 and proffered in September 2012. See 38 C.F.R. § 20.901(a) (2012). This opinion remedied the deficiencies in the previous opinions. The most recent remand was for consideration by the agency of original jurisdiction (AOJ) of evidence submitted by the Veteran in response to the VHA opinion, and for which he declined to waive consideration by the AOJ. 38 C.F.R. § 20.1304 (2012). The AOJ considered this evidence in a supplemental statement of the case issued in April 2013. Although not directed in the Board remand, the AOJ afforded the Veteran another VA examination in March 2013, and an opinion was proffered. The evidence of record contains service treatment and personnel records, VA treatment records and private treatment records, a lay statement from the Veteran's brother, treatise information provided by the Veteran, and lay statements from the Veteran. The Board concludes that no available outstanding evidence has been identified pertaining to the claim. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to this claim. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Criteria & Analysis Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1131; 38 C.F.R. § 3.303(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). Continuity of symptomatology under 38 C.F.R. § 3.303(b) can only be used to establish service connection in the case of a chronic disease listed in 38 U.S.C.A. § 1101; 38 C.F.R. § 3.309(a). Walker v. Shinseki, 706 F.3d 1331 (Fed. Cir. 2012). The record in this case suggests that one of the Veteran's current back disability may involve degenerative arthritis. Arthritis is one of the listed chronic diseases. 38 U.S.C.A. § 1101. In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368- 69 (2005). Listed chronic diseases, such as arthritis, are presumed to have been incurred in service if manifested to a compensable degree within one year of discharge from service; or if manifested in service and at any time thereafter. 38 U.S.C.A. §§ 1112, 1133; 38 C.F.R. §§ 3.303(b), 3.307, 3.309. In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court emphasized that lay testimony is competent if it pertains to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (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 the facts or circumstances and conveys matters that can be observed and described by a lay person). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran claims entitlement to service connection for back and leg numbness and other circulatory problems, which he asserts are due residuals of heat exhaustion or stresses and strains which he suffered during active service. It is noted that in an April 2011 decision, the Board denied entitlement to service connection for residuals of heat exhaustion. The Board concluded that the Veteran did not have any residual disability related to in-service heat exhaustion. As will be discussed in detail below, the medical evidence of record reflects degenerative arthritis of the lumbar spine and patellofemoral syndrome of the knees. Records also reflect hyperalgesia associated with chronic herpetic neuritis last ganglionitis. Service treatment records are negative for any complaints or treatment related to the back or legs. Service treatment records also do not reflect circulatory or neurological problems. Reports of Medical History dated in August 1978 and February 1981 reflect that the Veteran checked the 'No' boxes for 'recurrent back pain' and '"trick" or locked knee.' Reports of Medical Examination dated in August 1978, August 1979, and February 1981 reflect that his 'spine, other musculoskeletal' and 'lower extremities' were clinically evaluated as normal. Service treatment records reflect that the Veteran was treated for heat exhaustion in March 1982. The condition arose during a running drill. The Veteran stopped running and began staggering. At the time of treatment he reported no dizziness, nor loss of consciousness. Clinical examination showed a temperature of 102 degrees, excessive sweating, and disorientation. The examiner diagnosed heat exhaustion. He gave the Veteran intravenous fluids. The Veteran was instructed to maintain fluids for the remainder of the day and not participate in any physical exertion. There was no reported follow up treatment and no further findings recorded. A May 1983 Report of Medical Examination reflects that his "spine, other musculoskeletal" and "lower extremities" were clinically evaluated as normal. In August 1983, the Veteran certified that that there had been no significant changes in his health since his last medical examination. Per written statements in support of his claim, the Veteran asserts that the heat exhaustion documented in his service treatment records should have been diagnosed and treated as heat stroke. He asserts that due to the inadequate care he received for heat exhaustion, he has gradually developed severe spondylosis, circulatory problems, disk protrusions and degeneration, and numbness and swelling in his legs. In support of his claim, the Veteran submitted a December 2005 statement from Dean O'Hare, D.C., C.C.S.T., which reflects that the Veteran was seen on several occasions and Dr. O'Hare was aware of his on-going medical condition. He reviewed the Veteran's military and post-service medical records and concluded that he did suffer from a heat stroke and long-term residuals of this event. The heat stroke occurred while running in a military exercise in Okinawa, Japan while in the 3rd Reconnaissance Battalion. Dr. O'Hare stated that the Veteran also suffers from degenerative disc and spinal changes in the lumbar spine. Dr. O'Hare opined that this clearly could have been the result of the rigorous activities he was involved in while in the military. The degenerative changes are not felt to be the result of the heat stroke, but rather the repeated stress placed on the spine. In April 2010, the Veteran underwent a VA examination. The examiner noted service treatment records showing treatment for heat exhaustion/exertional heat injury, but found that he did not meet the criteria for heat stroke. In addition, the examiner noted that service treatment records did not show any spine injury or problems, but that the Veteran had documented degenerative joint disease/degenerative disc disease of the lumbar spine. The examiner found that, in the absence of better documentation, it was not possible to state whether the Veteran's present spine problems were related to his service without resort to mere speculation. Before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence. Jones v. Shinseki, 23 Vet. App. 382 (2010). The inability to opine on questions of diagnosis and etiology must be an assessment arrive at after all due diligence in seeking relevant medical information that may have a bearing on the requested opinion. In addition, a medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). The case was returned to the examiner for an addendum opinion, which was provided in May 2011. The examiner was asked to consider the Veteran's report of a continuity of symptoms, the June 2002 private report of a normal back, and the employment, private, and VA records. In addition, the Board advised that the Veteran is competent to report his symptoms and history, and such reports must be considered in formulating any opinions. The examiner was instructed to provide a reason if he discounted the Veteran's reports. However, in the May 2011 addendum opinion, the examiner noted only that the Veteran's service treatment records did not reflect any treatment for or diagnosis of a back/legs problem or a circulatory problem. It appears that the examiner did not take into account the Veteran's statements in rendering this opinion. In September 2012, a neurosurgeon employed by the VHA reviewed the claims folder and offered opinions. The examiner acknowledged the Veteran's 1982 episode of heat-related illness. The examiner noted that following his discharge from the military, the Veteran pursued a career with the postal service, starting in the mid-1990's. In 2001, he received a warning letter from his employer because he was noted to be at fault for a motor vehicle accident. His postal service vehicle was not parked properly. In 2005, the Veteran reported chronic low back pain that he reported began between 1982 and 1983. The VHA neurosurgeon opined that the Veteran's current spine disabilities are highly unlikely to be related to his in-service heat-related incident. The VHA examiner explained that there was no pathophysiological basis linking low back pain to heat-related illness. Consequently, the scientific literature contained no report of cases where a heat-related condition was associated with low back pain. The VHA examiner explained that heat-related illness was primarily an acute event that might lead to long-standing sequelae through the damage of susceptible organs. On the opposite, the low back pain is a chronic condition caused by a complex interplay of physical and psychosocial factors. The idea that a heat-related incident in 1982 would have caused tissue damage to the spine leading to the degenerative changes revealed in the MRI on February 2005 is highly improbable from a biological standpoint. Unlike other organs of the body, the tissues of the bony spine could endure wide changes in temperature and blood pressure without sustaining damage. The VHA neurosurgeon also opined that the Veteran's current spinal disabilities, chronic low back and pain and numbness of the extremities were unlikely related to his active service. The examiner noted that the Veteran's reports that his symptoms were present while on active duty from 1982 to 1983. The examiner also noted; however, that there was no documentation of the symptoms or work-up at that time. Treatment was sought only several years later (2005). On May 6, 2005, a private doctor (Dr. M.) noted that the numbness described corresponded more to hyperalgesia possibly related to herpetic neuritis. The examiner acknowledged Dr. O'Hare's opinion that his degenerative spine disease was related to the rigorous activity while on active duty, but the VHA examiner noted that Dr. O'Hare did not take into account several important factors. The February 2005 MRI showed a degree of degenerative disease primarily at the levels of L4/5 and L5/S1. This pattern of degeneration was compatible with normal aging. In support the neurosurgeon cited a 2009 study in which 1043 volunteers revealed that 90 percent of patients over the age of 50 had changes related to degenerative spine disease on their lumbar spine MRI; L4/5 and L5/S1 were the most commonly degenerated levels (Spine 2009; vol 34, N.9, pp.934-940). Therefore, the changes seen on the Veteran's MRI were more consistent with the long-standing and progressive wear and tear seen with degenerative spine disease rather than an acute change related to a discrete event in the past. The VHA examiner stated that as previously discussed, chronic low back pain was caused by a complex interplay between physical and psychosocial factors. Dr. O'Hare suggested that the intense physical activity while on active duty caused the low back pain. Although physical activity; such as pushing, pulling and lifting; had been associated with back pain, certain studies had seen a higher incidence with driving and monotonous work associated with stress. The neurosurgeon opined, based on the occurrence of the Veteran's medical complaints, it appeared that the back pain was more closely correlated in time with his occupation as a mail carrier than his time in active duty. The work of a mail carrier poses several risks for back pain: monotonous and repetitive activity, psychological stress (responsibility following motor vehicle collision in 2000), lifting, prolonged walking. The VHA examiner also noted that the Veteran displayed lifestyle risk factors for chronic low back pain. He smoked cigarettes until 1985. He was also obese based on a body-mass index of 37.7 reported in September 2006. These two modifiable factors are well-known to be associated with degenerative spine disease and chronic low back pain. The Veteran was evaluated by a neurosurgeon in May 2005. Based on the presentation and the imaging data, the neurosurgeon determined that most of the symptoms were related to epidural lipomatosis, a condition characterized by the presence of fat within the spinal canal. This condition may have various causes but it was seen in association with obesity. It was not related to intense physical activity. The VHA examiner noted that when evaluating low back pain it was important to take into consideration the psychosocial along with the physical factors that surround the Veteran's life. In the case of the Veteran, the MRI pointed toward a slow wear and tear process compounded with fat deposition in the spinal canal. Another neurosurgeon had determined that the fat deposition was responsible for several symptoms experienced by the Veteran including numbness and constipation along with back pain. The constellation of signs and symptoms comprised of degenerative spine disease at L4/5 and L5/S1, low back pain, epidural lipomatosis and a high body mass index, points to obesity playing a predominant role in the overall symptomatology of the Veteran. If one was to consider the importance of the Veteran's occupation, the risk factors associated with his most recent employment could not be ignored. The examiner noted that the Veteran was competent to report his history. The symptoms of back pain were reported to have started around 1982 to 1983. Nonetheless, the evidence on MRI showed a condition with a slow progression that matched more closely the occurrence of the first complaints of pain to the practitioners around 2005. Chronic pain was intrinsically a subjective and debilitating condition that affected most of the aspects of one's life. As such, distortion in the report of time of first occurrence is frequent and reflects the profound disturbance that pain brings to the Veteran's life. In a September 2012 Memorandum, the Chief of VA's Surgical Care Line, noted concurrence with the VHA neurosurgeons findings. In the March 2013 VA examination report; the examiner noted review of the claims folder. The examiner diagnosed lumbosacral strain with degenerative disc disease. The examiner opined that his chronic low back pain was less likely than not due to service. The examiner noted that service treatment records did not reflect any documentation of any clinic visits/treatment or management for any back related problem during active duty. The Veteran reported that being an officer prevented him from seeking help for health issues that he felt he was able to withstand or handle. There was no specific injury, motor vehicle accident, helicopter/parachute falls or assaults but he simply attributes the back pain to the intense physical rigors expected of his duties/military service. There was no documentation of thoracolumbar problem proximal to or within 5 years post discharge from military. The noted medical records from private medical doctors and VA documenting his lumbar spine pathology, dated at least 20 years after military separation. There was "no question of his lumbar spine disease." A neurosurgery consultation in 2005 recommended lumbar laminectomy to remove the epidural fact that is likely compressing the sacral roots but he declined at that time due to his work/family situation. The Veteran did not have a history of herpes zoster or nerve related injury that might be connected with neuronitis or ganglionitis. The RMS consult in 2005 mentioned a history of frequent "cold sores (oral)" that might possibly result in neuritis. This does not relate to his chronic low back pain especially in relation to his active duty. The Veteran could not recall the last cold sore episode. With regard to the knees, the examiner diagnosed patellofemoral pain syndrome. The examiner opined that his bilateral knee condition was less likely than not due to service. The examiner noted that service treatment records did not reflect any evidence or documentation of any clinic visits or treatment or management for any knees related problem during active duty. The Veteran stated being an officer prevented him from seeking help for health issues that he felt he was able to withstand or handle. He does not recall any history of specific injury, motor vehicle accident, helicopter/parachute falls or assaults but simply attribute this knee pain secondary back condition, to the intense physical rigors expected of his duties/military service. There is no documentation of knee problem proximal to or within 5 years post discharge from military service. There is no question of his knee pathology with his lumbar spine disease but there is no documentation of disease onset during and shortly after active duty. Of note, the Veteran does not have any history of herpes zoster or nerve related injury that may be connected with neuronitis or ganglionitis. RMS consult in 2005 mentioned a history of frequent "cold sores (oral)" that may possibly result in neuritis. This did not relate to the chronic pain at his knees. Analysis It is not in dispute that the Veteran experienced an incident of heat exhaustion during service in March 1982. His claim turns on the question of whether the he has back, leg or circulatory disorders due to this incident of heat exhaustion or whether any such disorders are otherwise due to service. The Veteran is competent to report a continuity of symptomatology, which he has done during the course of this appeal. As detailed, he has reported that his back, leg, and circulatory symptoms have been present since 1982 to 1983. His reports must be weighed against the negative findings in the service treatment records pertaining to any disorders affecting the back and legs, and the absence of any pertinent reports in the post-service treatment records prior to 2005. As detailed above, it was not until 2005 that degenerative disease of the lumbar spine was documented, and that he was clinically shown to complain of numbness in the extremities. Given that the contemporaneous record contradicts the Veteran's report of a continuity of symptoms, his report of such continuity is not credible. The Veteran's brother is competent to report the symptoms he has observed. The brother has reported that the Veteran began going to a doctor for some medical conditions to include swelling feet and back problems. The Veteran's brother could only provide competent evidence as to the symptoms he observed after service, and he did not report with any specificity when he began to observe the Veteran's symptoms. The brother's statement, therefore, does not serve to establish a link between service and any current disability. The Veteran submitted several medical articles regarding heat exhaustion and heat stroke. These articles are competent medical evidence, but the Board assigns them little probative value as they do not address the facts underlying the claim on appeal. They discuss the complications of heat stroke and the potential for heat exhaustion to become heat stroke, but they do not serve to show a relationship between heat exhaustion and the claimed disabilities or that the Veteran had heat stroke. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Id, at 303-4. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The September 2012 VHA examiner opined that it was highly unlikely that the Veteran's current spine disabilities were related to the in-service heat-related incident or traumas in service; and provided an opinion rebutting the Veteran's reports of a continuity of symptoms beginning in service. This opinion fully considered the entire record, including the Veteran's reports and the various medical opinions, expressed a definitive opinion and was supported by an extensive rationale Dr. O'Hare's opinion differs with the opinions of the September 2012 VHA examiner and March 2013 VA examiner with regard to whether the Veteran's back problems are otherwise due to active service. While Dr. O'Hare also found that his degenerative changes of the spine were not the result of the in-service heat related incident, Dr. O'Hare opined that his degenerative disc and spinal changes in the lumbar spine clearly could have been the result of the rigorous activities he was involved in while in the military, specifically repeated stress placed on the spine. Dr. O'Hare, however, did not consider the rigorous activities and repeated stress placed on the spine from the Veteran's long employment with the postal service or the reported accident during such employment. Hence, the opinion was not fully informed. The opinion also cited no specific medical literature or reasoning to support its conclusions; hence it was not supported by a reasoned analysis. The opinions of the September 2012 VHA examiner and March 2013 VA examiner are more persuasive and weigh against the claim. As detailed, the September 2012 VHA examiner found that his chronic low back pain and numbness of the extremities are unlikely related to his active service. Both examiners fully considered the record, provided definitive opinions and supported their conclusions with a thorough rationale. Nieves-Rodriguez v. Peake. The Board finds the opinions persuasive and plausible, as they are premised upon a thorough review of the evidence, and accompanied by an explanation. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The VHA examiner's opinion and the March 2013 VA examiner's opinion are the most probative evidence with regard to the question of whether there is a nexus between the current back and knee and neurological disabilities and service. See Boggs v. West, 11 Vet. App. 334 (1998). Given the depth of the reports, and the fact that the opinions were based on a review of the applicable record, the Board finds such opinions are probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). For the reasons just discussed, the Board finds the opinions of the VHA examiner and March 2013 VA examiner to be more probative than that of the private chiropractor. Additionally, there is no other competent and credible evidence of current back, leg, or circulatory disability related to service. Absent a showing of continuity of symptomatology, the question of whether the Veteran's back and knee and neurological disabilities are related to service would require medical expertise to answer. The Veteran's opinion that his current disabilities are related to a heat injury or stresses and strains during active service is not competent, because such an opinion would require medical knowledge. As explained by the VHA neurosurgeon, the causes of the Veteran's claimed disabilities are complex. The medical opinions of the September 2012 VHA medical examiner and March 2013 VA examiner (based on a review of the claims file and with knowledge of the Veteran's assertions) were negative. These are the most probative pieces of evidence. In sum, the preponderance of the evidence is against the Veteran's claim. Reasonable doubt does not arise. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57 (1990). Service connection for numbness of the back and legs and additional circulatory disorders is denied. ORDER Entitlement to service connection for numbness of the back and legs and additional circulatory disorders, is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs