Citation Nr: 1321128 Decision Date: 07/01/13 Archive Date: 07/12/13 DOCKET NO. 05-33 680 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for residuals of a back injury. 2. Entitlement to service connection for residuals of a head injury, to include a tumor and chronic headaches. 3. Entitlement to service connection for residuals of a rib injury. 4. Entitlement to service connection for a leg disability. 5. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD S.J. Janec, Counsel INTRODUCTION The Veteran served on active duty from January 1943 to November 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office in Phoenix, Arizona (RO) that declined to reopen the previously denied claims. This case was remanded by the Board in April 2006 and November 2006 for additional development. The Board denied these claims in an August 2007 Board decision. In September 2012, the Board vacated the August 2007 decision and remanded for de novo consideration based on the receipt of additional service records pursuant to 38 C.F.R. § 3.156(c) (2012). In a February 2013 rating decision, the RO granted service connection for residuals of a right forearm injury. The remaining issues remained denied and have been returned to the Board for appellate review. 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). FINDINGS OF FACT 1. A chronic back disability is not shown in service, arthritis of the lumbar spine was not diagnosed within a year of service discharge, and the preponderance of the evidence fails to shows that the diagnosed lumbar stenosis and degenerative disc disease had its onset in service or is otherwise related to active duty, including an in-service injury. 2. Residuals of a head injury, to include a tumor and chronic headaches, are not shown in service, a tumor of the brain was not diagnosed within a year of service discharge, and the preponderance of the evidence fails to shows that the diagnosed chronic headaches had their onset in service or are otherwise related to active duty, including an in-service injury. 3. A chronic rib disability is not shown in service, arthritis of the rib cage was not diagnosed within a year of service discharge, and the preponderance of the evidence fails to shows that the Veteran has a currently manifest rib disability that had its onset in service or is otherwise related to active duty, including an in-service injury. 4. A chronic lower leg disability is not shown in service, arthritis of the knees or hips was not diagnosed within a year of service discharge, and the preponderance of the evidence fails to shows that the diagnosed hip or knee disabilities had their onset in service or are otherwise related to active duty, including an in-service injury. 5. Hypertension was not shown in service or within a year of service discharge, and the preponderance of the evidence fails to shows that the diagnosed hypertension had its onset in service or is otherwise related to active duty. CONCLUSIONS OF LAW 1. A low back disability was not incurred in or aggravated by active service, and arthritis of the lumbosacral spine may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309(a) (2012). 2. Residuals of a head injury, to include a tumor and chronic headaches were not incurred in or aggravated by active service, and a brain tumor or lipoma of the forehead may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309(a) (2012). 3. Residuals of a rib injury were not incurred in or aggravated by active service, and arthritis of the rib cage may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309(a) (2012). 4. A lower leg disability was not incurred in or aggravated by active service, and arthritis of the hips and knees may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309(a) (2012). 5. Hypertension was not incurred in or aggravated by active service, and may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was provided appropriate notice in letters dated in August 2004, December 2006, April 2011 and December 2012, both prior to and subsequent to the rating decision on appeal. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and his representative suggest actual knowledge of the elements necessary to substantiate the claims. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the most recent March 2013 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence since the Board's September 2012 remand. VA has obtained examinations with respect to the claims on appeal and the examinations and opinions are adequate for rating purposes. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008); Barr v. Nicholson, 21 Vet. App. 303 (2007). Thus, the Board finds that there has been substantial compliance with the September 2012 remand and VA has satisfied the duty to assist provisions of law. Stegall v. West, 11 Vet. App. 268 (1998). Consequently, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in active service or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Evidence of continuity of symptomatology of a disability identified as chronic in 38 C.F.R. § 3.309(a) from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b) (2012); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Certain chronic disabilities, such as arthritis, brain tumors, or hypertension, if manifest to a degree of 10 percent or more within one year after separation from active duty, may be presumed to have been incurred in, or aggravated by, active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). When a veteran's service medical records are not available, the Board's duty to explain its findings and conclusions is heightened. There is a heightened duty of the Board to consider the resolving reasonable doubt in favor of the claimant, to assist the claimant in developing the claim, and to explain its decision when the veteran's medical records have been destroyed. O'Hare v Derwinski, 1 Vet. App. 365 (1991). The legal standard for proving a claim for service connection is not lowered, but rather the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the appellant is increased. Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Mercado-Martinez v. West, 11 Vet. App. 415 (1998); Cuevas v. Principi, 3 Vet. App. 542 (1992). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In adjudicating a claim, the Board must assess the competence and credibility of the claimant. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362 (2005). The Board also has a duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997); Wensch v. Principi, 15 Vet. App. 362 (2001). Additionally, competency of evidence must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67 (1997). Although interest may affect the credibility of testimony, it does not affect competency to testify. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). If all the evidence is in relative equipoise, reasonable doubt should be resolved in the claimant's favor, and the claim should be granted. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). However, if the preponderance of the evidence is against the claim, the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Factual Background The Veteran claims entitlement to service connection for residuals of a back injury, residuals of a head injury, residuals of a rib injury, a leg disability, and hypertension. Specifically, he claims that those disabilities were either caused by a single incident during service, or are secondarily related to disabilities which were caused by that incident. The incident in question occurred during a football game during training in early 1943, when the Veteran reported that he was knocked unconscious and suffered a broken arm, cracked ribs, and a head injury. It has been established that the Veteran's service medical records were unavailable and are presumed to have been destroyed in a fire at the National Personnel Records Center (NPRC) in July 1973. In August 2008, the NPRC successfully located sick reports from the Veteran's assigned unit dated from February 1943 to April 1943. Those reports state that the Veteran was transferred from duty to a hospital on February 23, 1943, and then was transferred from a hospital to duty on February 27, 1943. Accordingly, the Veteran's service records demonstrate that the Veteran experienced a medical situation during service of sufficient severity to result in a four night hospitalization. While the available records do not provide any details as to the cause of the Veteran's hospitalization, or his recovery afterwards, the Board notes that the incident occurred approximately three weeks into the Veteran's period of active service. The time frame is consistent with the Veteran's reported injury during training in early 1943. A private medical record dated in November 1950 shows that the Veteran was seen for the removal of a lipoma on his forehead. A private medical record dated in March 1974 shows that the Veteran was seen for a traumatic aneurysm of the left hand. A private medical record dated in July 1975 shows that x-rays of the ribs showed a slight irregularity at the costochondral junction of the sixth rib on the left. Hypertrophic changes of the dorsal spine and degenerative disc disease were also noted. Private medical records from the Nicolet Clinic dated from 1975 through 1988 have been submitted. At the time they were received, the Veteran noted that earlier records had been destroyed. In August 1975, he was seen for evaluation of hypertension. It was noted that he reported that he first became aware of hypertension approximately one and a half years prior when he was hospitalized for a surgical procedure. His past medical history noted a 1974 posttraumatic aneurysm of the palmar artery of the left hand and a 1950 appendectomy. He denied any other significant illnesses. In November 1983, he was seen for chronic intermittent headaches. He noted that they had been increased in the last several weeks. It was suspected that they were muscle contraction type headaches. In December 1984, he was seen for complaints of right paralumbar back pain. It was noted that he owned a restaurant and did some lifting and bending with products and supplies, but he did not recall any specific strain or injury to his back. He also noted that he had never had much in the way of a back injury or problem. The impression was lumbosacral strain. In November 1985, he was seen for left hip pain after he missed the running board on his car and stretched the hip. The assessment was persistent trochanteric bursitis. In March 1988, he was seen for left knee pain. He denied any trauma or injury. It was also noted that he was status post back surgery, but he still had pain in his back especially when he sat for a long period of time. In a January 1988 letter from D.G.P. M.D., it was noted that the Veteran was seen for chronic low back and bilateral leg pain consistent with neurogenic claudication. The assessment was high grade lumbar stenosis and an extruded disk at the L4-5 interspace on the left. A decompressive laminectomy was performed. In a June 1988 letter, P.B.M., M.D., of the Nicolet Clinic reported that he had been treating the Veteran for medical problems since 1975 that included essential hypertension, possible ischemic heart disease, hypercholesterolemia, spinal stenosis, degenerative arthritis of the lumbar spine, and chronic headaches. It was noted that the headaches seemed to be fatigue or stress related. In a February 1991 treatment record, the Veteran was seen for right knee pain following a fall in a local grocery store in July of the previous year. VA outpatient records dated from July 2000 through June 2004 denote treatment for back problems, hypertension, and other disabilities. A private medical record dated in August 2001 noted that the Veteran had fallen off a ladder and had some chest discomfort. His past history included a myocardial infarction in 1976 or 1978. He had high blood pressure and high cholesterol. In a March 2005 letter, P.B.M., M.D., now with the Affinity Medical Group reported that the Veteran's diagnoses over the last several decades included: essential hypertension; chronic headaches, thought to be stress-related; and joint pain. On VA back examination in January 2013, the Veteran's file was reviewed. The examiner noted that clinical evaluation of the back was not possible because the Veteran was unsteady and required a walker or wheelchair. The diagnosis was osteoarthritis of the spine. The examiner concluded that it was less likely that the Veteran's current spine disability was due to service, including the football injury because the medical records did not demonstrate that service was the origination of his back problems. Upon VA headaches examination in January 2013, the Veteran's file was reviewed. He gave a history of headaches since the time of his injury in service. The examiner concluded that the Veteran's current headaches were tension or muscle-related, and were less likely related to his service because the medical records documented that they began more than 30 years after discharge. Upon VA lower leg examination in January 2013, the Veteran's file was reviewed. He gave a history of leg problems since the time of his injury in service. The examiner concluded that the Veteran's current arthritis of the knees were less likely related to his service because the medical records documented post-service injuries. Upon VA hypertension examination in January 2013, the Veteran's file was reviewed. The examiner concluded that the Veteran's hypertension was not related to his service because the disease was first manifest more than 30 years after service. Upon VA bones examination in March 2013, the Veteran gave a history of sustaining a rib injury during a football game in service. He could not recall if they were broken or bruised. The file was reviewed. Clinical evaluation revealed no evidence of current rib residuals from the injury. The examiner stated it was less likely that there was any chronic disability as a result of the injury in service. Residuals of a Back Injury The record shows that the Veteran was hospitalized during service. His assertion of an injury while playing football has been conceded. His service medical records have been reported to be unavailable. The medical records do not show a diagnosis of arthritis of the lumbosacral spine within one year of his discharge from active duty. The earliest report of arthritis in the medical records is in 1975. Therefore, service connection may not be granted on presumptive basis. 38 C.F.R. § 3.309(a) (2012). Therefore, a competent medical opinion, or competent and credible lay evidence of continuity of symptomatology, is required to support the claim. However, neither has been sufficiently presented such that the claim may be granted. Upon VA examination in January 2013, the examiner concluded that it was less likely that the Veteran's currently manifested low back osteoarthritis was due to military service, including the reported football injury. Moreover, there are no virtually medical records documenting complaints of back pain or problems to satisfy the continuity of symptomatology requirement of § 3.303(b) until almost 30 years after discharge. In December 1984, he was seen for complaints of right paralumbar back pain. At that time, he did not recall any specific strain or injury to his back. He also noted that he has never had much in the way of a back injury or problem. Notably, he did not report any type of service injury at the time he sought medical care. A prolonged period without documented medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or disease was incurred in service, which resulted in any chronic or persistent disability. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Here, the lack of clinical evidence reflecting treatment pertaining to the lumbosacral spine until more than 30 years after his discharge from active service is against the Veteran's claim for service connection. To the extent that the Veteran and others have alleged continuity of symptomatology since discharge, the Board finds that they are competent to report about back pain or witnessing complaints of back pain during service and after discharge. Charles v. Principi, 16 Vet. App. 370 (2002); Layno v. Brown, 6 Vet. App. 465 (1994) (Veteran is competent to report symptoms because that requires only personal knowledge, not medical expertise, as it comes to him through his senses). Although lay persons are competent to provide opinions on some medical issues, the specific disabilities in this case arthritis, spinal stenosis, degenerative disc disease fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). These diseases are complex and require specialized training and medical diagnostic testing for a determination as to diagnosis and causation, and it are therefore not susceptible of lay opinions on etiology alone. Moreover, the private treatment records detailed above document subsequent incidents that caused back problems. None the records, which were prepared prior to the Veteran filing his claim for VA benefits, make reference to an in-service injury or chronic low back pain since service. The Board notes that had he been experiencing low back pain since the 1940s, as he alleges, it would have been in his best interest to report that to his treating physicians. Rucker v. Brown, 10 Vet. App. 67 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Consequently, the Board finds that the objective contemporary clinical evidence pertaining to the Veteran's medical problems is more probative and credible than later statements made in conjunction with a claim for VA compensation benefits. Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). Consequently, the Board finds that no probative weight can be assigned to the statements regarding experiencing low back pain or problems since service and cannot be accepted as competent evidence sufficient to establish service connection for a chronic disease listed in 38 C.F.R. § 3.309(a) pursuant to 38 C.F.R. § 3.303(b). The Board has considered resolving reasonable doubt in favor of the Veteran, particularly in light of the Veteran's missing service medical records. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). However, the evidence is not of such approximate balance as to leave reasonable doubt. O'Hare v Derwinski, 1 Vet. App. 365 (1991). Accordingly, the Board finds that the preponderance of the evidence is against the claim, and the appeal must be denied. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Residuals of a Head Injury, to include Tumor and Chronic Headaches The record shows that the Veteran was hospitalized during service. His assertion of an injury while playing football has been conceded. His service medical records have been reported to be unavailable. The medical records do not denote a diagnosis of a brain tumor within one year of his discharge from active duty. A lipoma was removed in 1950, four years after discharge. Therefore, service connection may not be granted on presumptive basis. 38 C.F.R. § 3.309 (a) (2012). Therefore, a competent medical opinion, or competent and credible lay evidence of continuity of symptomatology, is required to support the claim. However, neither has been sufficiently presented such that the claim may be granted. Upon VA examination in January 2013, the examiner concluded that it was less likely that the Veteran's currently manifested headaches were due to service, including the reported football injury. Moreover, there are no virtually medical records documenting complaints of headaches or head pain or problems to satisfy the continuity of symptomatology requirement of § 3.303(b) until almost 30 years after discharge. In November 1983, he was seen for intermittent headaches. At that time, he did not recall any specific injury to his head, including any type of service injury at the time he sought medical care. A prolonged period without documented medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or disease was incurred in service, which resulted in any chronic or persistent disability. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Here, the lack of clinical evidence showing treatment pertaining to the head until more than 30 years after discharge from active service is against the Veteran's claim for service connection. To the extent that the Veteran and others have alleged continuity of symptomatology since discharge, the Board finds that they are competent to report about head pain or witnessing complaints of headaches during service and after discharge. Charles v. Principi, 16 Vet. App. 370 (2002); Layno v. Brown, 6 Vet. App. 465 (1994) (Veteran is competent to report symptoms because that requires only personal knowledge, not medical expertise, as it comes to him through his senses). Although lay persons are competent to provide opinions on some medical issues, the specific disabilities in this case fall outside the realm of common knowledge of a lay person because there are various etiologies. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Moreover, the private treatment records document headaches that were muscular in nature rather than posttraumatic. None of those records, which were prepared prior to the Veteran filing his claim for VA benefits, make reference to an in-service injury or chronic headaches since service. The Board notes that had he been experiencing headaches since the 1940s, as he alleges, it would have been in his best interest to report that to his treating physicians. Rucker v. Brown, 10 Vet. App. 67 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Consequently, the Board finds that the objective contemporary clinical evidence pertaining to the Veteran's medical problems is more probative and credible than later statements made in conjunction with a claim for VA compensation benefits. Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). Consequently, the Board finds that no probative weight can be assigned to the statements regarding experiencing headaches or other head problems since service and cannot be accepted as competent evidence sufficient to establish service connection for a chronic disease listed in 38 C.F.R. § 3.309(a) pursuant to 38 C.F.R. § 3.303(b). The Board has considered resolving reasonable doubt in favor of the Veteran, particularly in light of the Veteran's missing service medical records. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). However, the evidence is not of such approximate balance as to leave reasonable doubt. O'Hare v Derwinski, 1 Vet. App. 365 (1991). Accordingly, the Board finds that the preponderance of the evidence is against the claim, and the appeal must be denied. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Residuals of a Rib Injury The record shows that the Veteran was hospitalized during service. His assertion of an injury while playing football has been conceded. His service medical records have been reported to be unavailable. The medical records do not show a diagnosis of arthritis of the ribs within one year of his discharge from active duty. Therefore, service connection may not be granted on presumptive basis. 38 C.F.R. § 3.309(a) (2012). Therefore, a competent medical opinion, or competent and credible lay evidence of continuity of symptomatology, is required to support the claim. However, neither has been sufficiently presented such that the claim may be granted. Upon VA examination in January 2013, the examiner concluded that the Veteran did not have any currently manifest residuals of a rib injury. Brammer v. Derwinski, 3 Vet. App. 223 (1992) (in the absence of proof of a present disability there can be no valid claim); Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (service connection may not be granted unless a current disability exists). Moreover, there are virtually no medical records documenting complaints of rib pain or problems to satisfy the continuity of symptomatology requirement of § 3.303(b) until almost 30 years after discharge. X-rays of the ribs in 1975, more than 25 years after discharge showed a slight irregularity at the costochondral junction of the sixth rib on the left. There was no notation of any type of service injury at the time he sought medical care. A prolonged period without documented medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or disease was incurred in service, which resulted in any chronic or persistent disability. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Here, the lack of clinical evidence showing treatment pertaining to the ribs until almost 30 years after discharge from active service is against the Veteran's claim for service connection. To the extent that the Veteran and others have alleged continuity of symptomatology since discharge, the Board finds that they are competent to report about rib pain or witnessing complaints of rib pain during service and after discharge. Charles v. Principi, 16 Vet. App. 370 (2002); Layno v. Brown, 6 Vet. App. 465 (1994) (Veteran is competent to report symptoms because that requires only personal knowledge, not medical expertise, as it comes to him through his senses). Although lay persons are competent to provide opinions on some medical issues, the specific disabilities in this case arthritis falls outside the realm of common knowledge of a lay person because diagnostic testing is required to identify the disability. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). None the private medical records, which were prepared prior to the Veteran filing his claim for VA benefits, make reference to an in-service injury or chronic rib pain since service. The Board notes that had he been experiencing rib pain since the 1940s, as he alleges, it would have been in his best interest to report that to his treating physicians. Rucker v. Brown, 10 Vet. App. 67 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Consequently, the Board finds that the objective contemporary clinical evidence pertaining to the Veteran's medical problems is more probative and credible than later statements made in conjunction with a claim for VA compensation benefits. Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). Consequently, the Board finds that no probative weight can be assigned to the statements regarding experiencing rib pain or problems since service and cannot be accepted as competent evidence sufficient to establish service connection for a chronic disease listed in 38 C.F.R. § 3.309(a) pursuant to 38 C.F.R. § 3.303(b). The Board has considered resolving reasonable doubt in favor of the Veteran, particularly in light of the Veteran's missing service medical records. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). However, the evidence is not of such approximate balance as to leave reasonable doubt. O'Hare v Derwinski, 1 Vet. App. 365 (1991). Accordingly, the Board finds that the preponderance of the evidence is against the claim, and the appeal must be denied. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Leg Disability The record shows that the Veteran was hospitalized during service. His assertion of an injury while playing football has been conceded. His service medical records have been reported to be unavailable. The medical records do not show a diagnosis of arthritis of the hips or knees within one year of his discharge from active duty. The earliest report of arthritis of any of those joints in the medical records is in 1975. Therefore, service connection may not be granted on presumptive basis. 38 C.F.R. § 3.309 (a) (2012). Therefore, a competent medical opinion, or competent and credible lay evidence of continuity of symptomatology, is required to support the claim. However, neither has been sufficiently presented such that the claim may be granted. Upon VA examination in January 2013, the examiner concluded that it was less likely that the Veteran's currently manifested lower leg disabilities were due to military service, including the reported football injury. Moreover, there are virtually no medical records documenting complaints of lower leg pain or problems to satisfy the continuity of symptomatology requirement of § 3.303(b) until almost 30 years after discharge. Notably, he did not report any type of service injury at the time he sought medical care. A prolonged period without documented medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or disease was incurred in service, which resulted in any chronic or persistent disability. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Here, the lack of clinical evidence showing treatment pertaining to the lower legs, including the knees and hips until more than 30 years after his discharge from active service is against the Veteran's claim for service connection. To the extent that the Veteran and others have alleged continuity of symptomatology since discharge, the Board finds that they are competent to report about leg pain or witnessing complaints of leg pain during service and after discharge. Charles v. Principi, 16 Vet. App. 370 (2002); Layno v. Brown, 6 Vet. App. 465 (1994) (Veteran is competent to report symptoms because that requires only personal knowledge, not medical expertise, as it comes to him through his senses). Although lay persons are competent to provide opinions on some medical issues, the specific disability in this case arthritis, falls outside the realm of common knowledge of a lay person because diagnostic testing is required to identify the disability. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Moreover, the private treatment records document subsequent incidents that caused leg and hip problems. None those records, which were prepared prior to the Veteran filing his claim for VA benefits, make reference to an in-service injury or chronic lower leg pain since service. The Board notes that had he been experiencing leg pain since the 1940s, as he alleges, it would have been in his best interest to report that to his treating physicians. Rucker v. Brown, 10 Vet. App. 67 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Consequently, the Board finds that the objective contemporary clinical evidence pertaining to the Veteran's medical problems is more probative and credible than later statements made in conjunction with a claim for VA compensation benefits. Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). Consequently, the Board finds that no probative weight can be assigned to the statements regarding experiencing leg pain or problems since service and cannot be accepted as competent evidence sufficient to establish service connection for a chronic disease listed in 38 C.F.R. § 3.309(a) pursuant to 38 C.F.R. § 3.303(b). The Board has considered resolving reasonable doubt in favor of the Veteran, particularly in light of the Veteran's missing service medical records. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). However, the evidence is not of such approximate balance as to leave reasonable doubt. O'Hare v Derwinski, 1 Vet. App. 365 (1991). Accordingly, the Board finds that the preponderance of the evidence is against the claim, and the appeal must be denied. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hypertension The Veteran's hypertension was not manifest in service or within one year of his discharge from service. His service medical records are not available; however, the private medical records do not suggest the presence of hypertension until the late 1960s or early 1970s, over 20 years after discharge from service. There is no competent medical, or competent and credible lay evidence establishing a relationship between the Veteran's military service and his currently manifest hypertension. Upon VA examination in March 2013, the examiner concluded that it was less likely that the disability had its onset during military service. The Veteran is competent to report that he experienced elevated blood pressure readings in service and since service. However, he is not competent to diagnose essential hypertension. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Additionally, the Board finds that the Veteran's assertions are not credible in light of the contemporaneous medical reports that do not show that the Veteran had any clinical findings showing a elevated blood pressure in service or in the immediate years following his separation. Consequently, the Board finds that the objective contemporary clinical evidence pertaining to the Veteran's medical problems is more probative than later unsupported statements made in conjunction with a claim for VA compensation benefits. Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). Consequently, the Board finds that no probative weight can be assigned to the statements regarding experiencing elevated blood pressure since service. Moreover, the Board observes that there are no medical records documenting complaints of elevated blood pressure or essential hypertension to satisfy the continuity of symptomatology requirement of § 3.303(b) until decades after discharge. A prolonged period without documented medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or disease was incurred in service, which resulted in any chronic or persistent disability. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Here, the lack of clinical evidence showing treatment pertaining to hypertension until many years after his discharge from active service is against his claim for service connection. Hence, the Board concludes that service connection may not be granted for this disability on a direct basis or on a presumptive basis as a chronic condition pursuant to 38 C.F.R. § 3.309(a). The Veteran has been provided with ample opportunity to present competent medical evidence to support his claim. However, he has not done so. 38 U.S.C.A. § 5107(a) (West 2002) (it is a claimant's responsibility to support a claim for VA benefits). In the absence of any persuasive evidence that the Veteran's current hypertension is etiologically related to active service, service connection is not warranted and the claim must be denied. As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). ORDER Service connection for residuals of a back injury is denied. Service connection for residuals of a head injury, to include a tumor and chronic headaches, is denied. Service connection for residuals of a rib injury is denied. Service connection for a leg disability is denied. Service connection for hypertension is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs