Citation Nr: 1319504 Decision Date: 06/17/13 Archive Date: 06/27/13 DOCKET NO. 08-31 354 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected degenerative disc disease, L5-S1. 2. Entitlement to service connection for a right knee disorder, to include as secondary to service-connected degenerative disc disease, L5-S1. 3. Entitlement to service connection for a left ankle disorder, to include as secondary to service-connected degenerative disc disease, L5-S1. 4. Entitlement to service connection for a right ankle disorder, to include as secondary to service-connected degenerative disc disease, L5-S1. 5. Entitlement to service connection for a neurologic disorder, to include small fiber disease of the upper extremities, to include as secondary to service-connected degenerative disc disease, L5-S1. 6. Entitlement to service connection for a neurologic disorder, to include small fiber disease of the lower extremities, to include as secondary to service-connected degenerative disc disease, L5-S1. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD David S. Nelson, Counsel INTRODUCTION The Veteran served in the Army National Guard and had active duty for training from June 1990 to October 1990 and active duty from April 1992 to September 1992 and from January 2003 to September 2003. These matters come before the Board of Veterans' Appeals (BVA or Board) from a June 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. This case was most recently before the Board in November 2012 and was remanded for further development. Following the requested development, the VA Appeals Management Center (AMC) in Washington, D.C., confirmed and continued the denials of the disabilities on appeal and the case has been returned to the Board for further appellate action. In August 2010 the Veteran testified during a Board hearing before the undersigned at the RO. A transcript of that hearing is of record. FINDINGS OF FACT 1. A disease or injury of the Veteran's left knee did not have onset during her active service, was not caused by her active service, and was not caused or aggravated by a service-connected disability. 2. A disease or injury of the Veteran's right knee did not have onset during her active service, was not caused by her active service, and was not caused or aggravated by a service-connected disability. 3. A disease or injury of the Veteran's left ankle did not have onset during her active service, was not caused by her active service, and was not caused or aggravated by a service-connected disability. 4. A disease or injury of the Veteran's right ankle did not have onset during her active service, was not caused by her active service, and was not caused or aggravated by a service-connected disability. 5. The Veteran has not had a neurological disorder of the upper extremities at any time since, or just prior to, when she filed her claim in September 2006. 6. The Veteran has not had a neurological disorder of the lower extremities at any time since, or just prior to, when she filed her claim in September 2006 CONCLUSIONS OF LAW 1. The criteria for service connection for disability of the left knee have not been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.310 (2006); 38 C.F.R. § 3.303 (2012). 2. The criteria for service connection for disability of the right knee have not been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.310 (2006); 38 C.F.R. § 3.303 (2012). 3. The criteria for service connection for disability of the left ankle have not been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.310 (2006); 38 C.F.R. § 3.303 (2012). 4. The criteria for service connection for disability of the right ankle have not been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.310 (2006); 38 C.F.R. § 3.303 (2012). 5. The criteria for service connection for a neurologic disorder of the upper extremities have not been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.303 (2012). 6. The criteria for service connection for a neurologic disorder of the lower extremities have not been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Duty to Notify Proper notice from VA must inform the claimant and representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any 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 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). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. The Veteran was notified via a letter dated in December 2006 of the criteria for establishing service connection, the evidence required in this regard, and her and VA's respective duties for obtaining evidence. She also was notified of how VA determines disability ratings and effective dates if service connection is awarded. The Veteran has not been informed, via RO correspondence, of the criteria for establishing service connection on a secondary basis. The Board notes that the Veteran had no service-connected disability at the time she filed this claim in September 2006. At any rate, not all notice errors require corrective action. Rather, the question is whether 38 C.F.R. § 19.9 requires that the matter be remanded for correction of the error as such action is essential for a proper appellate decision. This the Board views in light of the rule of prejudicial error, which provides that if the error is not prejudicial to the claimant, it is harmless error and therefore requires no correction. See generally Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (explaining the rule of prejudicial error in the context of claims for VA benefits). Here, the Veteran was provided with a supplemental statement of the case in August 2012 that included the regulatory text (38 C.F.R. § 3.310) explaining to her what is required for grants of secondary service connection. A person reading this document would understand what was required to substantiate the secondary service connection claim. Further, at the August 2010 Board hearing the Veteran demonstrated a basic knowledge of secondary service connection claims and made argument in that regard. Based on the foregoing, together with the opportunity that the Veteran has had to meaningfully participate in the processing of this matter, that is, to offer argument and to submit evidence or request that VA obtain evidence, the Board finds that there has been no prejudice to the Veteran resulting from the defects in VCAA notice concerning secondary service connection claims and that a remand is not necessary to inform the Veteran of that which a person would already understand given the facts of this case. As VCAA notice was not completed prior to the initial AOJ adjudication of the claims, such notice was not compliant with Pelegrini. However, as the case was readjudicated thereafter, there is no prejudice to the Veteran in this regard. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Duty to Assist Service treatment records are associated with the claims file, as are identified VA and private medical records. In June 2011 and November 2011 responses the Social Security Administration (SSA) indicated that they had none of the Veteran's medical records on file or were unable to locate any of the Veteran's medical records. In September 2011 RO correspondence the Veteran was informed that VA had been unable to obtain her SSA records and she was asked to submit any copies of such records in her possession. In November 2012 the Veteran underwent a VA examination that addresses the medical matters presented by this appeal. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinion obtained in this case is more than adequate. The November 2012 VA examiner elicited information concerning the Veteran's military service and performed a contemporaneous physical examination. The opinion considered the pertinent evidence of record and provided a rationale for its conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The November 2012 VA examiner also addressed the questions as directed by the Board's prior remands. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). During the August 2010 Board hearing, to assist the Veteran, the undersigned (page 14) asked questions to determine if there was any evidence outstanding pertinent to her claims. The undersigned also asked questions (page 19) to help direct the Veteran's testimony concerning the onset of her claimed disabilities. The undersigned also informed the Veteran that the record would be held open for 60 days in an effort to give the Veteran additional time to submit evidence in support of the appeal. These actions fulfilled the duties in Bryant v. Shinseki, 23 Vet. App. 488 (2010), and the Veteran has not asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) or identified any prejudice in the conduct of the hearing. As such, the Board finds that, consistent with Bryant, the Board complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claims based on the current record. The Board finds that there has been substantial compliance with its March 2011 and November 2012 remand instructions. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Significantly, as noted, in November 2012 the Veteran underwent a VA examination that addressed the medical matters presented by this appeal and contained answers to specific questions enumerated in the March 2011 and November 2102 remands. Further, June 2011 nerve conduction studies have been associated with the claims file. The Veteran has not referenced any other pertinent, obtainable evidence that remains outstanding. VA's duties to notify and assist are met, and the Board will address the merits of the claims. Applicable Laws-Service connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a Veteran must show: (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. Holton v. Shinseki, 557 F. 3d 1362, 1366 (Fed. Cir. 2010). The term "veteran" is defined in 38 U.S.C.A. § 101(2) as a person who served in the active military, naval, or air service, and who was discharged or released under conditions other than dishonorable. Active military, naval, or air service includes active duty. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). It also includes any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty and any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. Id. An individual who has served on active duty is a Veteran while an individual who has served only on ACDUTRA and/or INACDUTRA must establish a service-connected disability in order to achieve Veteran status. Paulson v. Brown, 7 Vet. App. 466 (1995). Service connection for certain specified chronic diseases, such as arthritis and peripheral neuropathy (as an organic disease of the nervous system) may be established on a presumptive basis by showing that such disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. Secondary service connection may also be granted for a disability, which is proximately due to, the result of, or aggravated by, an established service-connected disorder. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Secondary service connection includes instances in which an established service-connected disorder results in additional disability of another condition by means of aggravation. Allen. The regulation which governs claims for secondary service connection, was amended during the pendency of this appeal, effective October 10, 2006. The current 38 C.F.R. § 3.310(b) sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. Given what appear to be substantive changes, and because the Veteran's claim (received in September 2006) was pending before the regulatory change was made, the Board will consider the version in effect before the change, which version favors the claimant. VA is required to evaluate the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the veteran served, the veteran's military records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). The Board notes that although all the evidence has been reviewed, only the most salient and relevant evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). While the Veteran's DD 214 reflects that she was ordered to active duty in support of Operation Enduring Freedom, and records indicate that the Veteran had service in Iraq in support of that mission, the Veteran has not asserted that she has the disabilities on appeal as a result of combat. I. Service connection for a left knee disorder, right knee disorder, left ankle disorder, and right ankle disorder The Veteran's primary assertion concerning these disabilities is that they have resulted as secondary to her service-connected low back disability. In an August 2008 decision the RO granted the Veteran service connection for degenerative disc disease, L5-S1, and assigned a rating of 20 percent, effective September 25, 2006. The Veteran asserts that she has tingling and numbness of the upper and lower extremities, and such contentions will be addressed later in this decision in the portion pertaining to neurological disorders. The issues concerning the ankles and knees focus primarily on the Veteran's orthopedic complaints. An August 1990 service treatment record noted that the Veteran complained of right foot pain following a 12 mile road march; the examination of the right foot was normal. A September 1997 service treatment record noted that the Veteran had bruises on her left leg after falling on a tailgate; other than bruises, no left leg disability was noted. An October 3, 1999 service treatment record indicates that the Veteran complained of pain from her right hip through the right knee, and pain from the lower back through the right heel; the complaints followed an annual physical fitness test. The corresponding line of duty report indicated that the Veteran's injury was in the line of duty. An October 6, 1999 follow up physician's report noted only acute lumbar strain. The Veteran specifically denied any foot or knee trouble on the medical history portion of a January 2003 deployment examination. An April 2004 record from the Veteran's private physician (J.E.M., MD) noted that the Veteran was "walking gaunt" and complaining of severe back pain. A June 2006 medical record noted that five months prior the Veteran had been in an automobile accident that resulted in muscle spasms throughout her body. An Army National Guard physical examination dated in August 2004 is of record. That examination revealed that no foot, musculoskeletal, or lower extremity disability was noted on clinical examination. In the corresponding August 2004 report of medical history the Veteran specifically denied that she had any foot or knee trouble. At a May 2007 VA joints examination the Veteran indicated that her knee and ankle problems had their onset in the late 1990s. She knew of no known injury and stated that her knees and ankles hurt because of her back disability. Physical examination of the knees revealed crepitus. X-rays of the knees revealed a small osteochondral defect at the medial tibial plateau on the left; no other significant abnormalities were noted. As for the ankles, calcaneal enthesophytes were seen, with no other abnormities noted. The diagnoses were bilateral knee sprain, resolved with residual pain, and bilateral ankle sprain, resolved with residual calcaneal enthesophytes. The examiner gave no opinion of etiology as to the knee and ankle sprain. At the August 2010 Board hearing the Veteran indicated that she had knee and ankle joint pain that she felt resulted "because of the gaunt of my body position and the way I have to walk for my back to be let up off of pressure and pain is throwing these other joints out of alignment like they should be." The Veteran stated that she had to alter her gait and alter the way she positioned her body in order to get comfort for her back. The Veteran stated that she did have some knee and ankle pain during service, but not to the degree it was currently; she did not seek treatment for knee and ankle pain during service. She could not remember when she first went to a doctor for knee and ankle treatment, but did remember that she had seen a Dr. Moody. The Veteran, through her representative, appeared to state that she had sought treatment for her ankles and knees within one year of her September 2003 discharge from service. The Veteran repeated her assertion that her back problems were causing ankle and knee problems due to the different way she had to walk and stand. In an August 2010 letter, the Veteran's private family practitioner (Dr. T.J.) stated that he had treated the Veteran for many years. Dr. T.J. noted that the Veteran had been diagnosed in 2006 with spondylolisthesis. Dr. T.J. commented as follows: It is reasonable to conclude that, based on [the diagnosis of spondylolisthesis], [the Veteran] suffers from lower extremity joint pain bilaterally. This pain is chronic in nature and is derived from abnormal weight bearing and chronic cartilage damage from an abnormal gait. This is consistent with the findings from imaging studies performed by the VA. At a May 2011 VA examination the Veteran indicated that she had started to have bilateral knee and ankle symptoms in 2002-03. She indicated that there was no known injury and that she did not seek an evaluation for the knees or ankles during service. Her current complaints included knee pain and "stabbing" pain in the ankles. Examination revealed bilateral knee strain and a normal examination of the ankles. At a November 2012 VA examination the Veteran indicated that she had started to have bilateral knee symptoms a year or so after her back condition began (characterized as the mid 2000s by the examiner). Her current complaints included daily knee pain with a severity of 8 out of 10. The examiner indicated that there was no documented degenerative or traumatic arthritis of the knees, and patellar subluxation was also not present. The diagnosis was knee tendonitis, bilateral. As for her ankles, the Veteran indicated that she had started to have bilateral ankle symptoms a year or so after her back condition. Her current complaints included daily ankle pain, with a severity of 4 out of 10. The examiner indicated that there was no degenerative or traumatic arthritis of the knees or other abnormalities noted. The diagnosis was ankle tendonitis, bilateral. The November 2012 VA examiner commented, in pertinent part, as follows: [The Veteran's] conditions of bilateral knee and ankles are less likely as not (less than 50%) related to, caused by, or aggravated by her time in the service. The November 2012 VA examiner provided the following rationale: 1. The [service treatment records] clearly show no onset of this condition in service. 2. The [claims file] shows that there were no symptoms or treatment for these conditions until 2006-2007 timeframe. The notes clearly document the back condition and other conditions. There is no mention of any knee or ankle condition. 3. There is no documentation of any injury in the service. But there is documentation of her being in a [motor vehicle accident] after the service in 2006 in from which her PCP documented musculoskeletal systems. 4. [The Veteran's] knee and ankle conditions are most likely due to aging, a [body mass index] being greater than 30 and possibly the post service [motor vehicle accident]. As to the matters related to the Veteran's service-connected back disability, the November 2012 VA examiner commented as follows: [The Veteran's] conditions of bilateral knee and ankles are less likely as not (less than 50%) related to, caused by, or aggravated by her [service-connected] back condition. The November 2012 VA examiner provide the following rationale: 1. [The Veteran's] back condition is mild in severity based on the objective findings in the private treatment notes and also confirmed on imaging results. 2. I disagree with Dr. TJ in that back condition can cause the knee/ankle conditions. This assertion [is] not supported by the severity of the disease. Specifically there is no gross misalignment that causes pelvic girdle abnormal angulation. This is based on the imaging results and the physical examination. Also there is no grossly antalgic gait on physical examination such that abnormal degeneration of the distal joints can occur. The evidence of record contains an opinion of etiology favorable (Dr. T.J.'s August 2010 opinion) to the Veteran's secondary service-connection claim and a November 2012 VA opinion that rejects the Veteran's claim. Greater weight may be placed on one physician's opinion over another depending on factors such as the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). Additionally, the thoroughness and detail of a medical opinion are among the factors for assessing the probative value of the opinion. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The professional credentials and experience of opinion providers are properly considered in assigning probative value. Sklar v. Brown, 5 Vet. App. 140, 146 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. Harris v. West, 203 F. 3d 1347, 1350-51 (Fed. Cir. 2000). "[M]ost of the probative value of a medical opinion comes from its reasoning." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). With these considerations in mind, the Board finds that the favorable opinion from Dr. T.J. has less probative value than the November 2012 VA examiner's opinion. While the August 2010 private opinion contained at least some rationale, the opinion was not specific as to the severity and nature of the Veteran's back disability. The November 2012 VA examiner, on the other hand, noted that the Veteran's back disability was just mild in severity, and further noted that the Veteran's back disability had no gross misalignment that would cause pelvic girdle abnormal angulation, as based on the imaging results and the contemporaneous physical examination. Further, the November 2012 VA examiner also noted that there had been no grossly antalgic gait on physical examination that would produce abnormal degeneration of the distal joints. The August 2010 private opinion did not address these factors and did not reference any specific clinical or diagnostic findings in support of the opinion. Significantly, the November 2012 VA examiner also reviewed, and commented upon, the August 2010 favorable opinion from Dr. T.J. and stated reasons for rejecting that opinion. The November 2012 examiner's rationale is the core and foundation of the opinion offered and carries great probative weight in this case. The November 2012 VA examiner provided a sound rationale for the opinion expressed, and it is clear that the opinion was based on a comprehensive review of the Veteran's medical history as well as a contemporaneous examination. The Veteran's assertions that her ankles and knees disability is secondary to her low back condition has been considered. To the extent that this is an opinion of a nexus between these conditions, the Board finds her statement is not competent evidence. Whether a layperson opinion as to a nexus or a diagnosis is competent evidence depends on the facts of the particular case. See Davidson v. Nicholson, 581 F.3d 1313 (Fed. Cir. 2009). One factor for consideration is the complexity of the question to be determined. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (providing an example in footnote 4 that a layperson would be competent to diagnose a simple condition such as a broken leg but not competent to diagnose a form of cancer). Another factor is whether the question can be answered by personal observation alone. See Layno v. Brown, 6 Vet. App. 465, 496 (1994) (explaining that a layperson is competent to report only that which he or she observed). Whether one joint (in other words, the Veteran's back) can cause or aggravate tendonitis or other pathology in another joint (in this case, the knees or ankles) is not a question that can be determined by mere observation. The Veteran has provided no explanation as to the nature of such alleged relationship. Given that there is no logical or obvious relationship, it is not a simple question. For these reasons, the Board finds that her opinion in this regard is not competent evidence and therefore not probative of any fact in this case. Based on the foregoing, the Board concludes that the preponderance of the competent and credible evidence shows that the Veteran's knee or ankle tendonitis is not caused or aggravated by the service-connected low back disability. As for direct service connection, the Veteran's service treatment records reveal that an ankle or knee disability was not noted in service. This is evidence that she had no injury or disease of her ankles or knees during service or any symptoms of such and is therefore evidence unfavorable to her claim. While the Veteran apparently did not undergo a separation examination for the period of service from January 2003 to September 2003, an Army National Guard physical examination dated in August 2004 is of record. That examination revealed that no foot, musculoskeletal, or lower extremity disability was noted on clinical examination. As such, this report also tends to show that she had no ankle or knee disorder shortly following active service because it documents that she essentially had normal ankles and knees. In the corresponding August 2004 report of medical history the Veteran specifically denied that she had any foot or knee trouble. This also does not show that she had an ankle or knee disability during service or shortly thereafter. The post service private medical records do not show or contain any evidence suggesting a relationship between knee and ankle disability and the Veteran's service. If anything, such records tend to show that the Veteran's ankle and knee disability are related to the 2006 motor vehicle accident referenced in those records. The November 2012 VA examiner specifically stated that the Veteran's knee and ankle tendonitis were not related to the Veteran's military service as there was no objective evidence to support such a finding. This report is evidence against the Veteran's claims. The Board affords the November 2012 VA report considerable probative value because the examiner provided a compelling and logical rationale for the ultimate conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (explaining that most of the value of a medical opinion comes from its reasoning). In essence, the Veteran in this case is relying on her own reports of in-service knee and ankle symptoms as a basis for awarding compensation benefits. To the extent that she argues that an in-service injury caused her current ankle and knee tendonitis, the Board finds her statements are not competent evidence. Taking the aforementioned Davidson, Jandreau, and Layno together leads the Board to the conclusion that the complexity of the question, such as whether asserted in-service sprains or joint pain results into tendonitis can not be determined by direct observation and is not a simple question. Her opinion in this regard is not competent evidence and is not favorable to her claims. As for continuity of symptomatology since service, the Board notes that it appears that the Veteran has not been diagnosed with arthritis of the ankles or knees. Indeed, to the extent that such an assertion has been made, the Board draws attention to the September 2004 Army National Guard examination conducted shortly after service wherein the Veteran and clinical examination noted no knee or ankle pain or abnormality. Had she been experiencing such pain since service, it would have been logical for her to make such complaints at that time. A review of the evidence has revealed that a disease or injury of the Veteran's ankles or knees did not have onset during her active service, was not caused by her active service, and was not caused or aggravated by a service-connected condition. As the preponderance of evidence is unfavorable to her claims, the Board must deny her appeal as to entitlement to service connection for bilateral ankle and knee disorders. There is no reasonable doubt to be resolved as to these issues. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. II. Service connection for a neurologic disorder, to include small fiber disease of the lower and upper extremities. The Veteran asserts that she has a neurological disorder of the upper and lower extremities manifested by numbness and tingling that is related to her service-connected low back disability. Service treatment records reveal multiple complaints of pain that radiated from the Veteran's back, primarily to her lower extremities. The Veteran's low back diagnoses included spondylosis and spondylolisthesis L3-4. While lower extremity weakness and complaints of radiating pain where made during service, the service treatment records appear to contain no neurological diagnosis pertaining to the upper or lower extremities. Records from the Veteran's private chiropractor dated in November 2002 reflected that the Veteran complained of right arm pain and tingling as well as pain that radiated to her right leg. An Army National Guard physical examination dated in August 2004 revealed that no neurological disability was noted on clinical examination. In the corresponding August 2004 report of medical history the Veteran indicated that she had numbness or tingling. An April 2004 private record from the Veteran's private physician (J.E.M., MD) noted that the Veteran had been diagnosed with disability including spondylolisthesis and right radiculopathy. The Veteran also had right leg positive straight leg raising test. The basis for the diagnosis of right radiculopathy was not noted. A June 2006 record from Dr. J.E.M. noted that the Veteran was requesting to see a neurologist. The private physician stated, however, that "to a neurological exam, I find nothing wrong." An October 2006 record noted that the Veteran had recently undergone neurological testing (brain scan, MRI, EEG) that had revealed nothing wrong. Dr. J.E.M. indicated that there was no permanent neurological sequela. At a May 2007 VA examination the Veteran complained of numbness of the upper and lower extremities that she stated had begun at the time of her 1997 back injury. Following physical examination a diagnosis of small fiber disease with normal sensory exam was reported for the upper and lower extremities. Numbness of the upper and lower extremities was listed as a problem associated with the diagnosis. It was noted that nerve conduction studies and electromyography had not been undertaken in arriving at the reported diagnoses. At the August 2010 Board hearing the Veteran indicated that she began experiencing symptoms with her legs and arms immediately after her in-service back injury. She indicated that she would have pain shooting all the way down the whole extremity of the legs that would sometimes subside and that about a year later all her extremities started to tingle and have muscle jerks and pulls. She also reported a burning sensation in her legs. She stated that she has had the symptoms at all the times since service. She stated that during service she saw a military doctor when she had first injured her back and also saw a private physician and a chiropractor within a year after leaving service. At a May 2011 VA examination the examiner essentially indicated that a diagnosis of the Veteran's complaints related to peripheral nerve pain would be delayed pending nerve conduction testing. VA nerve conduction study (NCS) and electromyography (EMG) testing in June 2011 was normal, concluding that there was no electrophysiologic evidence of peripheral neuropathy or lumbar radiculopathy. At a November 2012 VA examination the examiner noted the Veteran's medical history, including that in June 2011 she had undergone NCS/EMG testing. The examiner indicated that the Veteran had symptoms of peripheral neuropathy that included intermittent pain and moderate paresthesia of the upper and lower extremities. In the diagnosis portion of the examination it was noted that the Veteran did not have a peripheral nerve condition or peripheral neuropathy. The examiner commented as follows: There is no neurologic condition identified on today's examination. This is based on a normal examination on today's examination. [The Veteran] has subjective complaints but there are no objective findings on physical examination. I disagree with the prior diagnosis of small fiber disease from the examination in 2007. This examination was also completely normal in that there [where] no sensory or strength findings on objective examination. Furthermore, the gold standard test for neuropathy in 2011 was completely normal. This case turns on the current disability element of a service connection claim. The preponderance of the evidence of record shows that the Veteran has not had a neurolgic disability of the upper or lower extremities during the course of her claim and appeal. The private treatment records from Dr. J.E.M. are not favorable to the Veteran. While an April 2004 record did note right radiculopathy and a positive right straight leg test, later records from the same physician such as those dated in June 2006 and October 2006 noted no neurological disability, with Dr. J.E.M. noting that the Veteran had no permanent neurological sequela. The May 2007 VA examination, with its diagnosis of small fiber disease of the upper and lower extremities, is likewise not favorable to the Veteran. The May 2007 VA examiner specifically noted that the diagnosis was rendered without any diagnostic testing such as nerve conduction studies and electromyography. In the same manner, the May 2011 VA examiner essentially indicated that a proper diagnosis of the Veteran's complaints related to peripheral nerve pain could not be made pending nerve conduction testing. As noted, such testing, conducted in June 2011, unequivocally concluded that there was no electrophysiologic evidence that the Veteran had any peripheral neuropathy or lumbar radiculopathy. The Board finds the opinion from the November 2012 VA examiner to be the most probative opinion in this case as to the question of whether the Veteran currently has or has had a neurologic disorder since filing her claim in September 2006. The November 2012 VA examiner's opinion was based on a contemporaneous examination and also was based on the most up to date evidence of any opinion or diagnosis rendered in this case. The November 2012 VA examiner's opinion was based in large measure on the June 2011 VA nerve conduction studies, a test that was not of record when the May 2007 VA examiner's diagnosis of small fiber disease had been given. The June 2011 VA nerve conduction studies are uncontradicted as it were, in that there is no other diagnostic study of record indicating a different result. As the November 2012 VA examiner's opinion was based in large part on a physical examination and the June 2011 VA testing, the November 2012 VA examiner's opinion is therefore afforded highly probative value by the Board. The Veteran is competent to report symptoms of her upper and lower extremities such as numbness, tingling, and the radiation of pain from her back disability. Nothing in the record, however, demonstrates that the Veteran received any special training or acquired any medical expertise in diagnosing neurological disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Whether she has a neurologic condition is not within the realm of knowledge of a layperson. As already discussed, diagnostic tests and interpretation of those tests by a medical professional are probative of whether a neurologic condition exists. This tends to show that diagnosing a neurological condition is a complex matter and not determinable merely by observation of the senses. For these reasons, the Board finds the Veteran's lay diagnosis is not competent evidence in this regard. The preponderance of evidence is against a finding that the first element of a service connection claim for a neurological disorder has been met at any time since the Veteran filed her claim. Additionally, the preponderance of evidence is against a finding that she was accurately diagnosed with a neurological disorder just prior to filing her claims. Therefore the appeal as to the lower and upper extremities neurologic disorder must be denied. Brammer v. Derwinski, 3 Vet. App. 223. 225 (1992); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, ---Vet. App. ----, No. 11-3272, 2013 WL 1907369 (May 9, 2013). There is no reasonable doubt to be resolved as to these issues. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for a left knee disorder is denied. Service connection for a right knee disorder is denied. Service connection for a left ankle disorder is denied. Service connection for a right ankle disorder is denied. Service connection for a neurologic disorder, to include small fiber disease of the upper extremities, is denied. Service connection for a neurologic disorder, to include small fiber disease of the lower extremities, is denied. ____________________________________________ JAMES G. REINHART Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs