Citation Nr: 1320152 Decision Date: 06/21/13 Archive Date: 07/02/13 DOCKET NO. 05-00 275A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for a disability of the hands and feet, to include as cold injury residuals. ATTORNEY FOR THE BOARD T. Mainelli, Counsel INTRODUCTION The Veteran served on active duty from July 1946 to April 1949 and from November 1949 to October 1958. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2003 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In pertinent part, the RO found that new and material evidence had not been received to reopen a claim of service connection for frostbite/cold injury residuals of the hands and feet. The Veteran died in January 2010. Consequently, in an April 2010 decision, the Board dismissed his appeal regarding the current appellate claim. However, the Board also noted that this decision did not affect the right of an eligible person to file a request to be substituted as the appellant for purposes of processing the claim to completion. The Veteran's surviving spouse was subsequently recognized as the substituted Appellant in this case pursuant to 38 U.S.C.A. § 5121A (West 2002 & Supp. 2011). The Board observes that during his lifetime, the Veteran was represented by a State veterans service organization (VSO) in his appeal. In March 2012, the Appellant submitted a VA Form 21-22 (Appointment of VSO as Claimant's Representative) in which she designated a different VSO as her representative for her appeal before the Board. However, in April 2012, that VSO declined to accept representation of the Appellant in this appeal. The Board informed the Appellant of this fact by correspondence dated in May 2012, as well as her various options to include appointing a new representative. Her only response was to submit a duplicate copy of the March 2012 VA Form 21-22 which, as already noted, was not accepted by the designated VSO. Therefore, the Board will proceed with the Appellant as unrepresented. In a decision dated August 2012, the Board reopened a claim of entitlement to service connection for a disability of the hands and feet, to include as cold injury residuals, and remanded the claim to the agency of original jurisdiction (AOJ) for further evidentiary development. The case now returns for further appellate review. A review of the Virtual VA electronic records storage system reveals copies of VA clinic records and VA adjudicative actions which are also associated with the paper claims folder and have been considered by the AOJ. The Board finally notes that, in August 2012, the Board remanded a claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), for further development. A January 2013 RO rating decision granted service connection for PTSD, and assigned an initial 50 percent rating effective November 5, 2001. As such is a full grant of the benefit sought on appeal, such issue is no longer on appeal. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT A disability of the hands and feet is not shown to be causally or etiologically related to any disease, injury, or incident in service, to include as residual to cold injury. CONCLUSION OF LAW The criteria for entitlement to service connection for a disability of the hands and feet, to include as cold injury residuals, have not been met. 38 U.S.C.A. §§ 1110, 1112, 1154(b), 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and 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)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. Here, a pre-adjudicatory letter dated February 7, 2002 advised the Veteran of the types of evidence and/or information deemed necessary to substantiate his service connection claim as well as the relative duties on the part of VA and himself in developing his claim. The Appellant, having been substituted for the Veteran in this case, was presumably aware of the same information as the Veteran. Moreover, the Appellant was provided with VCAA-notification letters in September 2010 and November 2011 regarding her claim of entitlement to dependency and indemnity compensation (DIC) benefits, which was adjudicated by a November 2011 rating decision. Although these letters did not specifically refer to the present appellate claim, it does reflect the Appellant was notified and aware of VA's basic duties to assist and notify. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (VA can demonstrate that a notice defect is not prejudicial if it can be demonstrated ... that any defect in notice was cured by actual knowledge on the part of the appellant that certain evidence (i.e., the missing information or evidence needed to substantiate the claim) was required and that the appellant should have provided it.); see also Overton v. Nicholson, 20 Vet. App. 427 (2006). The Board acknowledges that the letters provided to the Veteran did not include the information regarding disability rating(s) and effective date(s) mandated by the holding in Dingess v. Nicholson, 19 Vet. App. 473 (2006). However, he was provided with this information in the August 2007 SSOC as well as in the context of increased rating claims for already service-connected disabilities via letters dated in January 2007 and February 2007. Although such notice is not to be provided in an SSOC and such letters did not specifically relate to the current appellate claims, it does reflect that the Veteran was apprised of this information. See Mayfield, supra. Moreover, as the claim for service connection for a disability of the hands and feet is denied, any question as to the disability rating or effective date to be assigned is rendered moot. Therefore, the Board finds that the Appellant is not prejudiced by the Board proceeding with adjudication of this appeal. See Bernard v. Brown, 4 Vet. App. 384 (1993). In any event, the Appellant has not demonstrated any prejudice with regard to the content of any notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard, supra; Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (harmless error). In view of the foregoing, the Board finds that the Veteran and Appellant were notified and aware of the evidence needed to substantiate the claims and the avenues through which he or she might obtain such evidence, and of the allocation of responsibilities between themselves and VA in obtaining such evidence. Accordingly, there is no further duty to notify. Next, VA has a duty to assist the claimant in the development of the claim. This duty includes assisting the claimant in obtaining any outstanding records of identified VA or private medical treatment relevant to the claim, and affording him/her an examination and/ or opinion when appropriate. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board notes that the Veteran's service treatment records (STRs) may not be available. In such a situation, VA has a heightened duty to consider the applicability of the benefit of the doubt rule and to assist in the development of a claim. Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) citing Russo v. Brown, 9 Vet. App. 46, 51 (1996). See also Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). In his original service connection application received in 1959, the Veteran reported incurring a cold injury in Korea in February 1951. He described treatment in both a medical dispensary and a Mobile Army Surgical Hospital (MASH) unit. These records are not available and these facilities would no longer be in existence. Notably, the record does contain some treatment records from Korea while he served in the 4th Signal Battalion Corps in 1951 and 1952. The RO has obtained the Veteran's claimed treatment records at U.S. Army Hospital in Fort Gordon which appear to be complete, and include two entries related to cold injury complaints. As early as May 1959, the Veteran had been sent a letter requesting him to provide any evidence in his possession regarding his cold injury residual treatment. The RO has attempted an alternative records search, but the National Personnel Records Center (NPRC) reported that there are no additional STRs available. As such, the Board finds that it would be futile to make any further attempts to obtain STRs. 38 C.F.R. § 3.159(c)(2). Otherwise, the RO has obtained all pertinent, identified, and obtainable records. Notably, during his lifetime, the Veteran reported that treatment records for postservice treatment of cold injury residuals were unavailable due to his physician's death. See VA examination report dated July 2003. Therefore, the Board finds that VA has satisfied its duty to assist in this regard. VA has also obtained medical opinion based upon review of the claims folder as deemed necessary to substantiate the claim. The examination report, dated November 2012, reflects an accurate review of the factual history as deemed by the Board. The opinion describes the type of clinical findings to be expected from a cold injury, and explains why the Veteran's neurologic complaints which he attributed to cold injury residuals were related to other disease processes other than a cold injury. The Board finds that the examiner has provided the best possible opinion based upon review of the evidentiary record, and the fact that the Veteran was not available for actual examination. In August 2012, the Board remanded this case for additional development. The RO has fully complied with the remand directives by obtaining an adequate VA opinion, readjudicating the case, and providing the claimant a supplemental statement of the case. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand). For the foregoing reasons, the Board finds that VA has satisfied its duties to inform and assist the claimant at every stage in this case. As such, the claimant will not be prejudiced by a decision on the merits of this claim. II. Applicable legal criteria The Appellant seeks to establish the Veteran's entitlement to service connection for residuals of a cold injury. During his lifetime, the Veteran reported suffering a cold injury while service in Korea in February 1951 and having persistent neurologic symptoms involving the hands and feet since that time. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In general, 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). Certain chronic diseases may be presumed to have been incurred in service if manifest to a compensable degree within one year from discharge from service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 are also satisfied. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. § 3.309(a). For the showing of chronic disease in service, there are required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. However, the continuity and chronicity provisions of 38 C.F.R. § 3.303(b) only apply to the chronic diseases enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997) (applying 38 C.F.R. § 3.303(b) to a chronic disease not listed in 38 C.F.R. § 3.309(a) as "a substitute way of showing in-service incurrence and medical nexus.") Cold injury residuals are not deemed a chronic disease under 38 C.F.R. § 3.309(a), although Raynaud's disease is deemed a chronic disease under 38 C.F.R. § 3.309(a). During his lifetime, the Veteran claimed having been a prisoner of war (POW). A final August 2012 Board decision denied his claim for entitlement to recognition of POW status. As such, any presumptions relating to POW status are not applicable in this case. The Veteran is service-connected for PTSD due to combat exposure in Korea. A combat veteran's assertions of an event during combat are to be presumed if consistent with the time, place and circumstances of such service. 38 U.S.C.A. § 1154(b); see also Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996). The provisions of 38 U.S.C.A. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996). The provisions of 38 U.S.C.A. § 1154(b) do not establish service connection for a combat veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service. 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 Veteran. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). III. Analysis The Veteran had his first period of active service from July 1946 to April 1949. There is no lay or medical evidence that the Veteran incurred a cold injury during this period of active service. The Veteran had a second period of active service from November 1949 to October 1958. During his lifetime, the Veteran reported incurring a cold injury in February 1951. His reported field and hospital treatment records in Korea are not available. The record does reflect that, in March 1952, the Veteran incurred right finger trauma. At that time, an x-ray examination reflected no evidence of joint or bone pathology. In September 1952, the Veteran had a verruca plantaris on his heel pared and frozen with CO2. A December 1953 Medical Evaluation Board (MEB) examination did not reflect a history of the Veteran having a cold injury. Physical examination reflected normal clinical evaluations for his vascular system, upper extremities, feet, lower extremities and skin. A January 1954 hospitalization record generally noted that the Veteran's lower extremities demonstrated no edema with good peripheral pulses. An October 6, 1956, record from U.S. Army Hospital, Fort Polk, reflected the following assessment: Hx of frostbite hands & feet. Numbness this AM, when outside. Pt advised to wear gloves whenever possible. LD yes. A November 9, 1956, treatment record reflected the following assessment: Complains of numbness hands & feet (same complaint 8 Oct) works outside - Rx indoor work if possible. Priscoline LD yes. The Veteran's August 1958 discharge examination did not disclose any residuals of a cold injury with physical examination reflecting normal clinical evaluations for his vascular system, upper extremities, feet, lower extremities and skin. By means of a VA Form 21-526 (Veteran's Application for Compensation or Pension) filed in March 1959, the Veteran filed a service connection claim for cold injury residuals. He claimed incurring a frostbite injury in February 1951 initially treated in Korea. He also reported treatment at the U.S. Army Hospital in Fort Gordon. In a statement received in May 1959, the Veteran described frostbite residuals which included an inability to use his hands in cold weather. However, service connection was denied for frostbite residuals of the hands and feet by a May 1959 rating decision. Thereafter, the Veteran's medical records reflect his subsequent treatment for coronary artery disease in the early 1980s, tinea pedis in 1983 and peripheral vascular disease (PVD) in 1984. In the early 1990s, the Veteran was diagnosed with rheumatoid arthritis and began treatment with methotrexate and prednisone. An October 1991 VA clinic record noted that the Veteran "[d]escribes Raynauds (frostbite 1950's)." He was diagnosed with a B-12 deficiency in 1993 due to questionable pernicious anemia. In March 1994, x-ray examinations of his hands, wrists, and knees were interpreted as showing probable rheumatoid arthritis changes. A December 1997 VA clinic record noted the Veteran's history of frostbite injury in 1951 with no permanent sequelae except for numbness in the fingers and hands. Thereafter, a June 2002 VA clinic record noted the Veteran to have impressive tenosynovitis of the right wrist as well as tenosynovitis involving the left wrist, his fingers and other joints. In July 2003, the Veteran underwent VA Compensation and Pension (C&P) cold injuries examination. At that time, the Veteran described military duties of performing outdoor communications work in mountainous terrain in Korea where the temperatures were -40 degrees. On one occasion, his hands and feet became numb, cold, black and swollen. He then experienced skin peeling requiring a three day hospitalization involving wrapping his hands and feet in warm bandages. He had a similar episode of symptoms after service which also required hospital treatment. He generally described recurring episodes of his hands and feet turning numb, swollen and black with skin peeling. He pointed to a scar on the dorsum of his foot which he attributed to his cold injury. He further described Raynaud's syndrome wherein his fingers and toes would become pale with cold exposure and then turn blue. He reported numbness, especially in the fingertips and toe tips. The Veteran described a chronic throbbing pain, different in character from his rheumatoid arthritis, which was relieved by elevation. He endorsed onychomycosis of the toenails with his nails being thickened, yellowish and hypertrophic. He complained of pitting edema of the lower extremities with skin that was thinner and paler than normal. He described his feet as hurting at night resulting in sleep disturbance. He had a cold feeling regardless of outside temperatures. During winter, he wore several layers of clothes, thick socks, and kept the house temperature at 80 degrees. The Veteran denied recurrent tinea pedis and excessive sweating. On examination, the Veteran's skin color on the hands and feet was normal. There was 2+ pitting edema in the lower extremities. The feet and hands were cool to touch. The skin had a smooth texture, was dry and had no apparent atrophy. There was no obvious ulceration. Hair growth was diminished on the hands and legs. There was evidence of tinea pedis and onychomycosis in the feet. There was a V-shaped scar on the dorsum of the right foot with two limbs being 3 cm and 2.4 cm. at the widest aspect. The color of the skin was hypopigmented compared to the surrounding area. The scar was non-tender, not raised or depressed, and caused very mild cosmetic disfigurement. Range of motion for the wrists and fingers were normal. There was swelling in the hands and fingers. There were also nodules on the proximal interphalangeal (PIP) joints and swan-neck deformities as well as chronic swelling on the dorsum of the right hand consistent with a ganglion cyst. The peripheral pulses, dorsalis pedis and posterior tibialis were barely perceptible. Following diagnostic testing, the examiner provided the following impression: This is a 74-year-old [Veteran] with a history of frostbite injury sustained in service. He does have peripheral neuropathy, but his orthopedic picture is complicated by coexisting rheumatoid arthritis. Vascular studies indicate moderate small vessel disease. The Veteran's July 2003 x-ray examinations of the hands were interpreted as showing severe osteoarthritis with soft tissue swelling which could be due to gouty arthritis or synovial proliferative changes as may be seen in connective tissue arthritis. X-ray examinations of the feet were interpreted as revealing findings consistent with elements of both osteoarthritis and a synovial proliferative arthritis such as rheumatoid disease. A sensory nerve conduction and needle electromyography (EMG/NCV) study performed in August 2003 was interpreted as showing right upper extremity median peripheral neuropathy, and peroneal axonal neuropathy of the lower extremities. A May 2005 VA rheumatology visitation included the Veteran's report of burning sensation in both feet. His pain, which was mostly in the arch, was aggravated by walking/standing and relieved by rest. The pain was not bothersome at night. He further described pain in a dermatome distribution similar to a previous episode of Herpes. Physical examination demonstrated tenderness over the soles of the feet just distal to the calcaneus. The examiner provided an impression of probable plantar fasciitis. A subsequent VA clinic record in May 2005 included an assessment of neuropathy "(had severe frost bite when POW)" and maybe an element of plantar fasciitis due to his pain pattern "(worse when on feet, walking, oK at night)". The Veteran died in January 2010. In November 2012, a VA examiner provided an opinion based upon review of the claims folder. The examiner accurately summarized the STR entries and post-service lay description of symptoms, medical reports and diagnostic results. The examiner indicated that there was no evidence in the treatment records which would indicate that the Veteran had symptoms, physical findings or medications related to a diffuse distal peripheral neuropathy. The examiner indicated that it was less likely than not that the Veteran's disorders were incurred in or caused by an event during active service. The following rationale was provided: Treatment records indicate that the conditions of the hands and feet identified include Rheumatoid Arthritis, bilateral median neuropathy (carp[a]l tunnel syndrome), and suggestion of bilateral peroneal axonal neuropathy. There is no evidence to link any of these conditions to events during active service. "History of" in the notes dated 10/8/56 and 11/9/56. The discharge physical dated 8/26/58 is silent for frostbite condition or any sequelae which could be attributed to or suggestive of frostbite. There is no evidence in the STR or post active treatment records that would indicate that the reported symptoms of numbness in hands and feet in notes dated 10/8/56 and 11/9/56 developed into a chronic, condition. The condition of RA did not develop [sic] until many years later. The treatment records indicate EMG/NCV initially showed neuropathy right wrist in 1997 and repeat study in 2003 bilateral medican [sic] neuropathy and was suggestive of bilateral peroneal peripheral axonal neuropathy. The neurological which can potentially occur with severe cold injury would be seen in fine terminal cutaneous nerves and would be expected to produce a diffuse distal polyneuropathy. There is no evidence in the treatment records that would indicate Veteran had symptoms, physical findings, or medications related to a diffuse distal polyneuropathy. PN is not listed in the Problem List. There is no evidence in the STR or treatment records that support a diagnosis of diffuse polyneuropathy in the pattern expected from cold injury. Rather, the Veteran had mononeuropathies at the median and possible peroneal nerves which are attributable to his rheumatoid arthritis, a diagnosis which occurred many years after separation. On review of the entirety of the record, the Board finds that the preponderance of the evidence establishes that the Veteran suffered no permanent sequelae resulting from cold injury to the hands and feet during active service. Here, the Veteran reported suffering cold injuries to the hands and feet while serving in Korea, which is accepted as true. In this respect, the Veteran's report of working in a cold weather environment in Korea is consistent with his known circumstances of service, and corroborated by his October 1956 report of having a prior history of frostbite injury. His description of initial symptoms, including the feet and hands becoming numb, cold, black and swollen with skin peeling, is also accepted as true. Thus, the dispositive issue on appeal concerns whether the Veteran manifested any chronic residuals of his cold injury that occurred in February 1951. Notably, there is no lay or medical evidence that he incurred disability of the hands and feet during his first period of active service. The available evidence includes a formal military examination in December 1953 which reflected normal clinical evaluations of the Veteran vascular system, upper extremities, feet, lower extremities and skin. A January 1954 hospitalization record noted good peripheral pulses. These records, however, are not consistent with a finding of permanent sequelae from the February 1951 cold injury. STRs in October 1956 and November 1956 reflect complaints of hand and feet numbness when outside, which resulted in treatment with Priscoline and an advisement to wear gloves and work indoors if possible. These STRs did not reflect any clinical findings involving abnormalities of the vascular system, upper extremities, feet, lower extremities and skin. Similarly, the August 1958 examination which reflected normal clinical evaluations of the Veteran vascular system, upper extremities, feet, lower extremities and skin. The August 1958 separation examination is also not consistent with a finding of permanent sequelae from the February 1951 cold injury. Overall, the STRs are noteworthy only for the Veteran's report of hand and feet numbness when outside without any significant clinical findings. Post-service, the Veteran continued to complain of hand and feet numbness when exposed to cold. He referred to one hospitalization after service, and VA examiners in 1991 and 2003 commented that the Veteran described Raynaud's syndrome. However, the record contained no clinical corroboration that the Veteran demonstrated any chronic residuals from his cold injury in service, and there was no actual diagnosis or confirmation of Raynaud's syndrome. Rather, the Veteran's diagnostic testing found that he demonstrated right upper extremity median peripheral neuropathy, and peroneal axonal neuropathy of the lower extremities with no other detectable neurologic abnormalities. In November 2012, a VA examiner provided opinion that there was no evidence in the record to support a diagnosis of diffuse polyneuropathy in the pattern expected from a cold injury, and that the Veteran's mononeuropathies at the median and peroneal nerves were attributable to his rheumatoid arthritis. The only evidence tending to support a finding that the Veteran demonstrated permanent sequelae from his cold injury in service is the description of symptomatology by the Veteran himself. Clearly, the Veteran is competent to describe outwardly demonstrated and subjectively experienced symptoms. However, the Veteran is not competent to diagnose his symptoms as cold injury residuals as such concerns an internal physical process extending beyond an immediately observable cause-and-effect relationship, particularly in a case such as this with multiple co-existing diseases such as coronary artery disease, peripheral vascular disease, B-12 deficiency and rheumatoid arthritis. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In any event, the Board finds that the opinion of the November 2012 examiner holds significantly greater probative weight than the Veteran's personal opinion, as the VA examiner has greater expertise and training than the Veteran in speaking to complex medical issues of diagnosis and etiology. Moreover, the VA examiner based his conclusions on a review of the record and accepted medical principles, and offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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"). Therefore, the Board accords greater probative weight to the November 2012 VA examiner's opinion. In so finding, the Board acknowledges that Raynaud's disease is deemed a chronic disease under 38 C.F.R. § 3.309(a). However, the Veteran was not formally diagnosed with Raynaud's disease in service or within one year after service. Moreover, while an October 1991 VA clinic record and the July 2003 VA examiner noted that the Veteran described Raynaud's syndrome, neither actually provided a diagnosis of such disease. In fact, the July 2003 VA examiner determined that the Veteran had peripheral neuropathy, small vessel disease, and osteoarthritis with soft tissue swelling. Moreover, most recently, the November 2012 VA examiner determined, based on a thorough review of the record, that the Veteran had rheumatoid arthritis, bilateral median neuropathy, and a suggestion of bilateral peroneal axonal neuropathy. Raynaud's syndrome was not noted. Furthermore, the examiner found no basis to attribute the Veteran's reported neurologic symptoms experienced after service to the cold injury in service. In fact, he specifically dissociated such from the Veteran's cold injury. Thus, in the absence of a confirmed diagnosis of Raynaud's syndrome, the Board finds that the provisions of 38 C.F.R. § 3.309(a) are not applicable. The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claims process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). Here, the Board recognizes that the Veteran does manifest a disability of the hands and feet, but finds that the underlying disorders first manifested many years after service and are not causally related to an event in service. Accordingly, the Board finds that the Veteran suffered no permanent sequelae resulting from cold injury to the hands and feet during active service and, thus, the Veteran's claim for that benefit may not be granted. There is no reasonable doubt to be resolved. See 38 U.S.C.A. § 5107(b); Gilbert, supra. ORDER Service connection for a disability of the hands and feet, to include as cold injury residuals, is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs