Citation Nr: 1320825 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 03-24 947A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for osteoarthritis, to include as due to lead exposure. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran served on active duty from February 1951 to February 1955. This matter is on appeal from the Nashville, Tennessee, Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied entitlement to service connection for osteoarthritis (also claimed as bone problems due to exposure to lead batteries). In August 2007, the Board denied the claim. The Veteran appealed to the Veterans Claims Court. In November 2008, the Court Clerk vacated the Board's decision and remanded the case to the Board for development and readjudication consistent with a Joint Motion for Remand (JMR). In March 2010, the Board remanded this matter for a VA medical examination. The Board again remanded the case in February 2011 in order to obtain outstanding treatment records and for a VA medical examination and again in December 2012 for compliance with a February 2011 Board remand directive concerning the VA medical examination. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that where the remand orders of the Board are not complied with, the Board errs in failing to insure compliance). The requested action has now been accomplished satisfactorily, and the Board may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the file on the "Virtual VA" system to ensure a complete assessment of the evidence. 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 Osteoarthritis was not shown during service or for many years thereafter; it did not manifest to a compensable degree within one year of service separation, and the record contains no indication that osteoarthritis is causally related to active service or any incident therein. CONCLUSION OF LAW Osteoarthritis was not incurred in service, and such disability may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also 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). The Board notes that 38 C.F.R. § 3.303(b) applies herein because the Veteran's claimed disability (osteoarthritis) entails a "chronic disease" within the meaning of 38 C.F.R. § 3.309(a). See generally Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the Veteran's claims file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the Veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (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. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the Veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a Veteran or obtained on a Veteran's behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (reasonable doubt to be resolved in Veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a Veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran contends that during service he dismantled, cleaned, reassembled, charged, and discharged lead acid submarine batteries. He asserts that lead exposure resulted in bone problems, now diagnosed as osteoarthritis. The service treatment records contain no mention of arthritis, and the Veteran did not sustain any bone or joint injuries in service. On entry into service and on separation, all relevant bodily systems were assessed as normal. In a Report of Medical History completed by the Veteran just prior to discharge, he expressly denied arthritis as well as bone, joint, or other deformities. The first post-service clinical evidence of symptoms relating to arthritis is a February 2000 lumbar spine X-ray study that showed the lumbar vertebrae in good alignment, an anterior compression fracture of the L1 vertebra with loss of approximately one-third its anterior height, and prominent end-plate degenerative spurring from the T12-L1 and L1-2 disk spaces. A March 2000 Computed Tomography (CT) scan of the lumbar spine revealed mild hypertrophic degenerative disease as well as borderline spinal stenosis. According to a March 2000 VA medical report, the Veteran complained of low back pain related to a September 1998 accident where he fell off of a horse and landed on his sacral area. The physician noted that the Veteran had a history of degenerative arthritis. Examination revealed mild tenderness to palpation in the low lumbar paraspinal muscles, and range of motion was approximately 25 percent restricted in all planes with pain on the extremes of range of motion. An X-ray study showed mild to moderate hypertrophic degenerative disease with mild to moderate narrowing of the neural foramina of C3-C4 and C5-C6 on the left. There was chronic, mild loss of height of the body of C5 and mild disk space narrowing at C5-C6. A CT scan of the lumbar spine showed intact nerve roots and borderline spinal stenosis. There was mild circumscribed bulging disk with mild impingement to the thecal sac at L3-L4, L4-L5, and L5-S1 disks. There was mild hypertrophic degenerative disease at L4-L5. The diagnostic assessment was an L1 compression fracture and degenerative arthritis of the lumbosacral spine with chronic, intermittent low back pain. A July 2002 VA medical report reveals that the Veteran complaining of right foot pain. An X-ray study of the right foot indicated that the visualized osseous structures appeared intact with no evidence of fracture or destructive bone or joint disease. Calcaneal spurs projected both along the plantar surface and superiorly. In a November 2002 medical report, he complained of right foot pain and left hip pain. An X-ray study of the left hip revealed moderate osteoarthritis. There was mild loss of volume of the femoral head that was suggestive of early aseptic necrosis. There was no fracture or dislocation. According to a January 2003 medical report, the Veteran reported that his left hip hurt when he walked, and there was a shooting pain down his leg. He stated that he had been diagnosed with sciatica pain. The diagnoses were limb length discrepancy and right arch pain. An April 2003 medical report indicates that the Veteran complained of worsening left hip pain. Examination revealed an observable limp. There was full range of motion in the right hip without pain. Left hip flexion was decreased at 90 degrees, internal rotation was decreased at 15 degrees, and external rotation was severely decreased at 20 degrees. There was full range of motion in right hip abduction. Left hip abduction was decreased at 30 degrees. Lumbar forward flexion was decreased at 45 degrees, backward extension was decreased at 10 degrees, right lateral flexion was slightly decreased, and left lateral flexion was severely decreased at less than 10 degrees. The diagnosis was left hip osteoarthritis. In a May 2003 medical report, the Veteran complained that left hip pain was worsening, especially in a particular position when he walked. He denied a history of an injury to the left hip. Examination revealed an antalgic gait and marked restriction of motion in all planes of the left hip. There were no rotational movements or extension. Flexion was possible to 80 degrees, abduction was possible to about 20 degrees, and adduction was possible to about 10 degrees. A left hip X-ray study showed severe narrowing of the joint space with degenerative joint disease in the acetabular fossa and further deterioration than the previous year. The physician found that the Veteran's degenerative joint disease was stable. He also diagnosed left hip pain, rule out avascular necrosis, and recommended a total hip arthroplasty, which was subsequently performed at a private medical facility in 2004. In October 2003, the Veteran told a VA practitioner that he believed his skeletal problems were due to exposure to toxins. In a January 2004 letter, a VA podiatrist stated that he could not make the assumption that lead was instrumental in the Veteran's foot condition. He opined that the Veteran should attempt to make the correlation that lead caused the deterioration of the bones, which ultimately necessitated the hip replacement. He further opined that the Veteran should show that the hip replacement probably led to the limb length discrepancy and the foot condition. He stated that an orthopedic surgeon could verify that lead has been shown to cause bone deterioration, but medical evidence was required in order to assert that lead caused the Veteran's foot condition. In a May 2006 letter, a private physician, K.O., M.D., stated that she found in her research that submarine mechanics like the Veteran were exposed to asbestos, non-ionizing radiation, ultraviolet radiation, lead, noise from turbine engines, and heat as well as heavy physical work in hot environments. She stated that the Veteran suffered from aseptic necrosis of the hip and overall weakness of bones. She further reported that when lead entered the body, it caused the bones to weaken. She opined that although the Veteran might have developed at least some of his current conditions over his lifetime, the severity of his conditions was likely to have been created, accelerated, and/or exacerbated by the hazardous conditions to which he was exposed during service. She also opined that he was at a higher than average risk of developing additional medical ailments as a result of his exposure to asbestos and lead in service. The Veteran submitted numerous articles regarding lead poisoning, assessment of blood lead levels, and blood lead level testing. These articles provided, in pertinent part, that the standard elevated blood lead level for adults, according to the Center for Disease Control, is 25 micrograms per deciliter of whole blood. Furthermore, these reports stated that every adult has accumulated some lead contamination from lead paint, air emissions from leaded car exhaust, pollution from smelters, and drinking water that comes from lead pipes and other plumbing fittings. Another study held from 1976 to 1980 revealed that the median blood lead level for the entire United States population was 13 micrograms per deciliter. The Veteran's May 2006 blood lead level test revealed only 2 micrograms of lead per deciliter of blood. The Veteran testified at a May 2006 hearing before a Decision Review Officer at the RO. Testimony revealed that he worked on dismantling and recharging lead acid submarine batteries during service. He testified that he had done research that showed that lead could cause deterioration of the bones. He reported that he had no arthritic problems during active duty and that the only time he had ever been exposed to lead was during service. He further stated that he began to experience arthritic problems in the 1990's. The Veteran submitted a February 2010 letter from Dr. K.O. Dr. K.O. stated that in performing his occupational duties as a submarine mechanic in service, the Veteran was exposed to several environmental hazards related to the development of osteoarthritis. These were repetitive heavy work in awkward positions, non-ionizing radiation, and lead. According to Dr. K.O., it was at least as likely as not that the Veteran's osteoarthritis was related to the "exposures" he experienced while in service. All three exposures created weakness in the bones that led to chronic trauma and inflammation that was related to the arthritic symptoms that developed later. Repetitive heavy work in awkward positions as a submarine mechanic caused constant strain on the muscles, bones, and tendons. The strain of frequent squatting, climbing ladders, and lifting heavy loads set up microtrauma and the breakdown of tissue. Non-ionizing radiation played a role by disrupting the normal repair process of the tissue injured by repetitive activities. Lead exposure caused a buildup of lead in the blood that transferred into the bones. On February 2011 VA examination, the examiner indicated that the onset of the Veteran's osteoarthritis was in 1960. It is unclear whether this assertion was based on a report of the Veteran. The Veteran reported that he began to suffer from joint pain many years earlier but denied any trauma to the joints. He did not seek treatment for many years. According to the examiner, the Veteran was vague about his history of joint pain. The examiner diagnosed generalized osteoarthritis with pain predominantly in the shoulders and hips as well as status-post left hip replacement, which was associated with osteoarthritis. The examiner opined that the Veteran's osteoarthritis was not related to lead exposure. Rather, it resulted from the aging process. The examiner explained that the Veteran had not been diagnosed with any other disorders associated with lead exposure such as gastrointestinal colic, peripheral neuropathies/paralysis, renal disease, and anemia during or around the time of his potential exposure. The examiner further stated that he was not aware of any lead-associated arthritic conditions. Lead toxicity could elevate uric acid levels, which caused gout in some individuals. The Veteran had no symptoms of gout to include gouty arthritis. The Veteran's generalized osteoarthritis was appropriate for his age. Furthermore, there was no trauma to any particular joint during service. Thus, the examiner explained that the Veteran's osteoarthritis was not related to service or lead exposure therein. In a February 2013 addendum, the February 2011 VA examiner indicated that he did not agree with the assessment of Dr. K.O. He disagreed with Dr. K.O.'s conclusion regarding an association between lead exposure and the Veteran's osteoarthritis, as no lead toxicity was ever noted in the Veteran. Furthermore, he disagreed with Dr. K.O.'s assertions regarding non-ionizing radiation causing arthritis. The VA examiner indicated that this conclusion was speculative at best because that type of radiation was used to treat injuries such as with ultrasound therapy. Finally, the VA examiner indicated that he disagreed with Dr. K.O. regarding her assessment with respect to repetitive work and strain. The VA examiner explained that repetitive work and strain caused such injuries as tendonitis and bursitis, but there was no medical understanding that such activities caused osteoarthritis. Furthermore, the VA examiner indicated that there were no injuries noted in service that would indicate any particular overuse or repetitive use injury in service. At the outset, the Board observes that no osteoarthritis was shown in service or in the first post-service year. Indeed, there is no evidence of arthritis until years after service. The Board is aware that a VA examiner noted that the onset of osteoarthritis was in 1960, although there is no documentation of osteoarthritis in the claims file until 2000. At one time, the Veteran reported that the onset of osteoarthritis was in the 1990's. Regardless of the foregoing discrepancies, it is clear that years had elapsed between service separation and the onset of osteoarthritis. Consequently, service connection for the Veteran's osteoarthritis cannot be granted based upon chronicity in service, continuous symptoms of osteoarthritis from service separation to the present, or presumptively based upon diagnosis of a chronic disease (in this case osteoarthritis) within one year of discharge. Because the facts in this case do not warrant service connection based on chronicity in service, continuity of symptomatology from service separation to the present, or based upon diagnosis within a year of discharge, the only way in which service connection for the Veteran's current osteoarthritis can be established herein is if the evidence establishes that the disease was incurred in service. The pertinent evidence herein includes the Veteran's assertions, the conclusions of Dr. K.O., the opinion of the VA examiner, and the articles submitted by the Veteran. In weighing the evidence, the Board must consider the competency, credibility, and probative value of the evidence. As stated, the Veteran maintains that his osteoarthritis is due to lead exposure in service. The Board cannot rely upon his assertions for although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), osteoarthritis and its origins falls outside the realm of common knowledge of the lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Next, the Board assigns Dr. K.O.'s conclusions less probative value. Dr. K.O. is competent to provide medical opinions due to her medical training; however, her assertions are based on speculative data. Most saliently, she assumes that the Veteran sustained some degree lead poisoning without providing a rationale for that conclusion. The Board does not dispute the fact that he was in the vicinity of lead during service in a submarine. However, there is no evidence, either contemporaneous or otherwise, that the lead ever entered his body. Indeed and significantly, post-service testing weighs against such a finding because the lead levels in his body were far lower than the national median. As well, as subsequently explained by the VA examiner, there are diseases and conditions that are commonly associated with lead exposure. The evidence does not reflect that the Veteran ever suffered from any of those conditions. Next, the Board finds her assertions regarding non-ionizing radiation wanting, as she failed to discuss the impact of exposure to non-ionizing following service such as that associated with microwave ovens. As to her conclusions concerning strain on the muscles and joints from the Veteran's duties as a mechanic in service causing osteoarthritis, she did not explain why the Veteran's osteoarthritis was diffuse and not concentrated in the particular joints that were under strain in service. In short, Dr. K.O.'s reports are not thorough, and the Board, therefore, assigns them less probative value. See Prejean, 13 Vet. App. at 448-9 (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Board finds that the articles and studies regarding the consequences of lead exposure submitted by the Veteran are less probative due to the lack of evidence showing that lead entered his body in service or that he ever experienced lead toxicity in service. Again, the Board points to the evidence which shows that his lead levels are well below the national norm. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the duty to assess the credibility and weight to be given to the evidence). On the other hand, the Board finds the VA examiner's opinions of greater probative value. Of note, the VA examiner conducted a thorough examination of the Veteran, reviewed the claims file, and provided a full and complete rationale for his opinions and conclusions. As such, they are of great evidentiary weight. The examiner concluded that the Veteran's osteoarthritis was due to the aging process (the records show that he is 83 years old) and not service or any incident therein. Indeed, the VA examiner explained that there was no injury in service that would have caused the Veteran's osteoarthritis and there was no evidence of lead toxicity in service. Based on the VA examiner's competent and probative opinions, the Board finds that the Veteran's osteoarthritis is unrelated to service, and service connection for that disorder is denied. In sum, the entirety of the competent and probative evidence weights against the Veteran's claim. Thus, the evidence for and against the claim is not in relative equipoise, and the benefit of the doubt rule does not apply. As such, the appeal is denied. Finally, 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. 2012); 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This 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). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2) (West 2002). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. 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. Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in September 2002 that fully addressed all notice elements and was sent prior to the initial RO decision in this matter. The letter informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. With respect to the Dingess requirements, in November 2006, the RO provided the Veteran with notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. With that letter, the RO effectively satisfied the remaining notice requirements with respect to the issue on appeal. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In determining whether a medical examination be provided or medical opinion obtained, there are four factors to consider: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing an in-service event, injury, or disease, or manifestations during the presumptive period; (3) an indication that the disability or symptoms may be associated with service; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. With respect to the third factor, the types of evidence that "indicate" that a current disorder "may be associated" with service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). First, all relevant medical evidence was obtained. In addition, the Veteran was afforded a VA examination in connection with the claim. The Board finds that the VA examination and subsequent addendum are adequate for the purpose of deciding the issue of service connection for osteoarthritis. They contain sufficient information, to include that supplied by the Veteran, for a determination that osteoarthritis is unrelated to service. The Board is also satisfied that VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, the Veteran's statements, private medical records, and VA clinical records. Therefore, the available records and medical evidence have been obtained in order to make an adequate determination as to this claim. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance 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). ORDER Service connection for osteoarthritis is denied. ____________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs