Citation Nr: 1322090 Decision Date: 07/10/13 Archive Date: 07/18/13 DOCKET NO. 10-06 934 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUE Entitlement to service connection for arthritis of the left hand. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran, who is the Appellant in this case, had active service from October 1970 to August 1974, November 1978 to September 1981, and October 1984 to July 2000. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a June 2004 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this claim for issuance of a statement of the case in December 2009. A statement of the case was issued in January 2010. In October 2012, the Board remanded this case to the RO via the Appeals Management Center (AMC), in Washington, DC. The Board asked that the RO/AMC provide the Veteran a VA examination to obtain medical evidence as to the nature and etiology of the claimed left hand disability. The RO/AMC provided a VA examination in January 2013. As the requested development has been completed to the extent possible, no further action to ensure compliance with the remand directives is required. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), 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 Veteran's file on the "Virtual VA" system to ensure a complete assessment of the evidence. Additional evidence was associated with the claims file in April 2013 with a waiver of consideration by the agency of original consideration. FINDINGS OF FACT 1. No disease or chronic symptoms of arthritis of the left hand were manifested during service. 2. The Veteran did not continuously manifest symptoms of arthritis of the left hand in the years after service. 3. Arthritis of the left hand was not manifested to a degree of ten percent within one year of service separation. 4. The Veteran's arthritis of the left hand is not caused by any in-service event and is not related to active service. CONCLUSION OF LAW The criteria for service connection for arthritis of the left hand are not met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA 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. The Board finds that the VCAA notice requirements have been satisfied by letters dated in December 2003, March 2006, and December 2012. In these letters, VA informed the Veteran of the evidence and information needed to substantiate a claim for service connection and informed the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf. VA informed the Veteran it had to obtain any records held by any federal agency. These letters also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letters told the Veteran that he could obtain private records himself and submit them to VA. 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 a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the March 2006 letter explained the type of evidence necessary to establish service connection and the type of evidence necessary to establish a disability rating and effective date for the claims on appeal. The claim was readjudicated in the January 2010, November 2011, and February 2013 Supplemental Statements of the Case, thus curing any lack of timeliness of notice. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). VA has a duty to assist a veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board notes that the Veteran's service treatment records are associated with the claims folder. VA treatment records dated from January 2000 to July 2010 are associated with the claims folder. VA provided an examination in January 2013 to obtain medical evidence as to the nature and likely etiology of the claimed left hand disability and a medical opinion as to etiology was obtained. The examination is adequate because the examination was performed by a medical professional based on review of claims file, solicitation of history and symptomatology from the Veteran, and an examination of the Veteran. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA examiner considered the Veteran's service treatment records and provided a medical opinion as to whether the claimed disability was related to active service. Neither the Veteran nor his representative has challenged the adequacy of the examination obtained for the issue on appeal. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). For these reasons, the Board finds that the duties to notify and assist the Veteran have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board finds that no reasonable possibility exists that any other assistance would aid in substantiating the claim and VA met its duty to assist the Veteran. Laws and Regulations Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In this case, arthritis is listed among the "chronic diseases" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. 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). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). 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. See generally 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. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.102, 4.3, 4.7. Analysis The Veteran in this case contends that he developed arthritis in his left hand as a result of repeatedly doing push-ups during active service. He avers that, in the early 1990s, he developed acute pain in both wrists while doing push-ups for a physical fitness test. When his wrist pain became too severe, he started doing push-ups on his knuckles, which he says caused arthritis in the knuckles of both hands. See the Veteran's statements dated in February 2004. Service connection has been granted for degenerative joint disease of the right third metacarpophalangeal joint. Based upon a review of all the lay and medical evidence, the Board finds the weight of the competent and credible evidence shows that the left hand arthritis did not manifest in service or to a compensable degree within one year of service separation and is not otherwise related to active service. The Board finds the weight of the competent and credible evidence shows that the Veteran did not have chronic symptoms of a left hand disability in service or continuous symptoms after service. The Veteran is competent to report an observable symptoms such as pain. See Jandreau; supra. The record further shows that the Veteran has training as a nurse. Service records indicate that he worked as a clinical nurse and therefore, based upon this military occupation and training, the Board finds that the Veteran has some medical expertise and he may be competent to provide a medical opinion. The Board has the duty to assess the credibility and weight to be given to the evidence. See Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997), and cases cited therein. The Court in Madden held that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence". Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997). The Board finds that the Veteran's statements that he began to have severe hand pain in the 1990's to have limited credibility and, therefore, limited probative value, because the Veteran first made these statements 4 years after service separation and almost 10 years after the claimed event occurred, and the statements are not supported by lay and medical evidence of record. The service treatment records document complaints regarding the right index finger and right arm, but no complaints of severe pain in the left hand. The Veteran's service treatment records show that in October 1990, the Veteran reported a two month history of numbness in his right index finger associated with callous formation secondary to a bump on his tennis racquet. At that time, he reported feeling an electric shock whenever he bumped his finger. Physical examination revealed a positive Tinel's sign at the base of the right index finger, and the physician diagnosed a contusion. No mention was made of left hand or finger symptoms. Service treatment records dated in 1997 document complaints of pain in the left shoulder when doing pushups, not in the left hand. In January 1997, the Veteran reported shoulder pain when doing full push-ups. He sought treatment for the same problem on multiple occasions during that year, but at no time did the Veteran mention hand or wrist problems due to performing push-ups. A May 1997 MRI shows a diagnosis of degenerative joint disease of the left acromioclavicular joint. The May 2000 retirement examination report indicates that the Veteran reported painful joints, and the examining physician assessed arthritis, although the report does not specify which joints were affected. The examination report notes that the Veteran took Motrin for joint pain especially in the knees. The report also noted that the Veteran had bilateral knee pain and a left shoulder injury. The examination report does not document any complaints of pain in the hands and does not document a left hand disability. Examination of the upper extremities was normal. The Veteran filed a claim for disability compensation benefits in March 2000, prior to his discharge from service. He filed a claim for seven different disabilities. He did not file a claim for a left hand disability or report left hand symptoms. The Veteran was afforded a VA examination in April 2000. The VA examination report does not document any complaints or findings pertinent to the left hand and the Veteran did not mention any complaints pertinent to the left hand in his reported medical history; he reported having pain in the left shoulder with pushups and a dull ache in the left arm and biceps. A left hand disability was not detected or diagnosed. Physical examination of the extremities was negative. Examination of the upper extremities did not reveal any muscle atrophy or strength or sensory deficits. The VA treatment records do not document any complaints or findings pertinent to the left hand until 2003. The Veteran reported having chronic pain in the bilateral hands in June 2003. The Veteran filed a claim for disability compensation for a left hand disability in August 2003. The Veteran was afforded a VA examination in May 2004. The Veteran reported having frequent hand pain secondary to pushups in service. Physical examination of the left hand was negative. X-ray examination of the left hand revealed no abnormalities. It was noted that x-ray examination revealed subluxation of the first carpal metacarpal joint. A November 2005 x-ray examination revealed slight subluxation of the first carpal metacarpal joint with mild spurring. The January 2013 VA x-ray examination of the left hand revealed very mild degenerative changes of the third metacarpophalangeal joint with narrowing of joint space. The diagnosis was degenerative or traumatic arthritis. He VA examiner noted that a February 2006 x-ray examination first showed mild degenerative changes. The Veteran also submitted lay statements from service members and in the statements, the service members indicate that they recall the Veteran having hand pain in active duty. In the statements, the servicemembers stated that they remember the Veteran experiencing hand and wrist pain during active service, usually during or after physical training, but that he did not seek treatment for it. The claims file includes an August 2005 letter from Dr. P.R., who wrote that the Veteran was well known to her as a patient during her three year medical residency at Clark Air Force Base in the Philippines. She stated that the Veteran frequently consulted her for medical advice, and that one of his primary physical complaints was pain in both hands and wrists beginning in July 1990. She stated that these symptoms occurred while the Veteran was on a combat training exercise referred to as "Red Flag," conducted by the U.S. Air Force and the Philippine Army. During this exercise, the Veteran had to build a tent city, carry heavy objects, and do extensive field training, and he initially noted pain in the knuckles and wrists. She attributed this pain to osteoarthritis of both hands and wrists. See also the statement by Dr. P.R. dated in March 2013. In the March 2013 statement, Dr. P.R. stated that she was not able to make a note of treatment in his outpatient record as it was not available and the Veteran was treating the problem himself with Tylenol and aspirin. The Board finds that the service treatment records and examination reports are more probative than the Veteran's lay statements made in 2003 and since that time, the statements by service members and the statements made by Dr. P.R., all of which were made years after service. The service treatment records were created during the Veteran's period of active service and establish that the left hand was normal and that he had no complaints pertinent to the left hand. The Board also finds the Veteran's claim dated in March 2000 and the April 2000 VA examination report are more probative than the Veteran's lay statements made in 2003 and since that time, the statements by service members and the statements made by Dr. P.R. The Veteran's claim dated in March 2000 and the April 2000 VA examination report weigh against service connection for a left hand disability. The March 2000 claim indicates that the Veteran asserted that he had seven different disabilities that were incurred in service but he did not mention a left hand disability. The April 2000 VA examination report does not document any complaints pertinent to the left hand. Such absence of complaints, findings, or treatment at separation from service and upon the initial VA examination, in this context, is highly probative and contemporaneous evidence that the Veteran did not experience chronic left hand symptoms in service and soon after service. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (citing Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (Lance, J., concurring) (VA may use silence in the service treatment records as evidence contradictory to a veteran's assertions if the service treatment records appear to be complete and the injury, disease, or symptoms involved would ordinarily have been recorded had they occurred)). Had the Veteran been suffering from chronic left hand pain or other left hand symptoms, such complaints would have been reflected by his separation examination report, the initial compensation application, and the VA examination report. The VA examination report dated in April 2000 specifically asked him for a history of such complaints. Instead, the separation examination report and the April 2000 VA examination report do not document any complaints or symptoms. The fact that the March 2000 claim indicates that the Veteran asserted that he had seven different disabilities that were incurred in service but he did not mention a left hand disability suggests to the Board that there was no pertinent left hand throat disorder symptomatology at that time. While inaction regarding filing a claim is not necessarily indicative of the absence of symptomatology, where, as here, a veteran takes action regarding other claims, it becomes reasonable to expect that a veteran is presenting all issues for which he is experiencing symptoms that he believes are related to service. In this case, the Veteran demonstrated that he understood the procedure for filing a claim for VA disability compensation, and he followed that procedure in another instance where he believed he was entitled to those benefits. In such circumstances, it is more reasonable to expect a complete reporting than for certain symptomatology to be omitted. Thus, the Veteran's inaction regarding a claim for a left hand disorder, when viewed in the context of his action regarding other claims for compensation, may reasonably be interpreted as indicative of the Veteran's belief that he did not sustain an injury or disease manifesting a left hand disorder in service, or the lack of left hand disorder symptomatology at the time he filed the claim, or both. The Board finds that the lack of contemporaneous in-service complaints or treatment relating to the left hand, and the lack of a report of a history of chronic symptoms or findings of a left hand disability at the time of the Veteran's separation and soon after service establish that the Veteran did not have chronic left hand symptoms in service and soon after service. As indicated, at the May 2000 service separation examination and at the April 2000 VA examination, the Veteran's upper extremities were clinically evaluated as normal. Following service separation in May 2000, the evidence of record shows no complaints, diagnosis, or treatment for any left hand disability until June 2003, almost three years after service discharge. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor that tends to weigh against a claim for service connection). The absence of post-service complaints, findings, diagnosis, or treatment after service for several years until 2003 is one factor, considered in addition to the other factors stated in this decision, which tend to weigh against a finding of either chronic left hand symptoms in service or continuous symptoms of a left hand disability after service separation. See Buchanan, 451 F.3d at 1337 (holding that the Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence). While the Veteran is competent to state that he had left hand symptoms at any time, including in service, the Board finds that the Veteran's more recent assertions of chronic left hand symptoms in service and continuous left hand symptoms since service, made in the context of the August 2003 claim for service connection (VA disability compensation) for a left hand disability, are outweighed by the other, more contemporaneous, lay and medical evidence of record, and are not credible. See Charles v. Principi, 16 Vet. App. 370 (2002). The recent statements of chronic left hand symptoms in service and continuous post-service left hand symptoms are inconsistent with the service treatment record evidence and the VA examination conducted in April 2000 soon after service, including the Veteran's own reported medical history at the April 2000 VA examination, an absence of complaints or treatment for several years after service, and the histories and symptoms credibly reported by the Veteran during post-service VA and private treatment. The Board finds that the weight of the competent and credible evidence establishes that the Veteran did not sustain an injury or disease of the left hand during service, he did not experience chronic left hand symptoms in service, and he did not experience continuous post service symptoms of a left hand disability to include arthritis. See 38 C.F.R. § 3.303(b). The medical evidence of record does not establish chronic symptoms in service or continuous symptoms after service. Therefore, presumptive service connection pursuant to 38 C.F.R. § 3.303(b) for chronic in service symptoms and continuous post service symptoms is not warranted. The Board finds that the weight of the competent and credible evidence establishes that the claimed degenerative or traumatic arthritis of the left hand did not manifest within one year of service separation and first manifested many years after service separation. The first diagnosis of degenerative or traumatic arthritis of the left hand based upon x-ray findings is upon x-ray examination in about 2006. A May 2004 x-ray examination did not detect arthritis of the left hand. The November 2005 x-ray report notes spurring in the first finger of the left hand but a diagnosis of arthritis was not made. A February 2006 x-ray examination detected mild degenerative changes. Therefore, presumptive service connection pursuant to 38 C.F.R. § 3.309(a) for a chronic disease manifested to 10 percent within one year from service separation is not warranted. Finally, the Board finds that the weight of the evidence demonstrates that the degenerative or traumatic arthritis of the left hand is not caused by any in-service event or injury and is not related to service. The more probative evidence of record, specifically the January 2013 VA medical opinion, the service treatment records, and the April 2000 VA examination report establish that the arthritis of the left hand did not first manifest in service and is not medically related to service. The Veteran was afforded a VA examination in January 2013. The VA examiner reviewed the claims folder, considered the Veteran's reported medical history, examined the Veteran, and offered an opinion as to the etiology of the claimed left hand disability. The VA examination report notes that the Veteran reported having wrist pain and hand pain in service from doing pushups. The VA examiner reviewed the x-ray findings from service and after service and noted that degenerative joint disease was first noted in February 2006. The Veteran underwent physical examination and the diagnosis was left hand arthritis. The examiner opined that the Veteran's left hand pain secondary to mild arthritic disease was associated with age and inactivity and was less likely than not related to push ups in service or other activity in service. The Board finds the January 2013 VA medical opinion to have great evidentiary weight as the opinion reflects a comprehensive and reasoned review of the entire evidentiary record. The VA examiner reviewed the claims folder including the service treatment records and the Veteran's medical history, and examined the Veteran before rendering the medical opinion. The VA examiner specifically addressed the treatment and examination of the left hand in service and after service and discussed the examination findings and considered such findings when rendering the medical opinion. Factors for assessing the probative value of a medical opinion are the examiner's access to the claims file and the thoroughness and detail of the opinion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The medical opinion is based on sufficient facts and data. In Nieves-Rodriguez, 22 Vet. App. 295, the Court held that guiding factors in evaluating the probity of a medical opinion are whether the opinion was based on sufficient facts or data, whether the opinion was the product of reliable principles and methods, and whether the medical professional applied the principles and methods reliably to the facts of the case. For these reasons, the Board has assigned great probative weight to the opinion of the VA physician and finds that it outweighs the statements of the Veteran and Dr. P.R. The Board finds that the January 2013 VA medical opinion, the service treatment records, and the April 2000 VA examination report establish that the Veteran's left hand arthritis first manifested many years after service separation and is not related to active service but is due to the aging and inactivity. The Veteran submitted medical opinions in support of his claim. The Veteran himself has related the degenerative or traumatic arthritis of the left hand to his active service, specifically to in-service pushups. As noted above, the Veteran worked as a clinical nurse in service and has medical training as a nurse. He also submitted statements by Dr. P.R. in support of his claim. In statements dated in August 2005 and March 2013, Dr. P.R. indicated that the Veteran was well known to her as a patient during her three year medical residency at Clark Air Force Base in the Philippines. She stated that the Veteran frequently consulted her for medical advice, and that one of his primary physical complaints was pain in both hands and wrists beginning in July 1990. She stated that these symptoms occurred while the Veteran was on a combat training exercise referred to as "Red Flag," conducted by the U.S. Air Force and the Philippine Army. During this exercise, the Veteran had to build a tent city, carry heavy objects, and do extensive field training, and he initially noted pain in the knuckles and wrists. She attributed this pain to osteoarthritis of both hands and wrists. The Board finds that the opinions by the Veteran and Dr. P.R. to have limited probative value and are outweighed by the January 2013 VA medical opinion, the service treatment records, and the April 2000 VA examination report. The Board is not questioning the Veteran's expertise as a nurse or Dr. P.R.'s expertise as a medical doctor. However, the Board finds that the January 2013 VA medical opinion outweighs the Veteran's own medical opinion because the VA examiner, as a medical doctor, has more training and expertise. Some medical issues require specialized training for a determination as to diagnosis and causation. Some diagnoses, such as a diagnosis of arthritis, require clinical or diagnostic testing such as x-ray examination. The VA examiner based the medical opinion, in part, upon x-ray examination. It does not appear that the Veteran based his opinion upon x-ray examination. Additionally, an opinion of etiology would require knowledge of the complexities of the musculoskeletal system and the various causes of arthritis and would involve objective clinical testing that the Veteran did not appear to perform in his role as a nurse. The Board may also consider the Veteran's own self interest in formulating a medical opinion in support of his own claim for compensation benefits. Thus, the Board finds that the January 2013 VA medical opinion to have more probative value than the Veteran's own medical opinion as to nexus. The Board finds that the January 2013 VA medical opinion to have more probative value than the opinion by Dr. P.R. because the opinion by Dr. P.R. is based upon facts that have been rejected by the Board. As discussed in detail above, the Board found that the more probative evidence establishes that the Veteran did not have chronic symptoms of left hand pain in service, thus, since Dr. P.R.'s medical opinion is based upon the inaccurate premise, this medical opinion has limited probative value. Further, the January 2013 VA medical opinion is based upon review of the entire claims file and the Veteran's medical history including x-ray examinations performed since service. Dr P.R. did not indicated that the claim folder was reviewed or that she reviewed the x-ray examination reports, which are necessary to substantiate a finding of arthritis. Medical opinions based upon insufficient facts and data or based upon an inaccurate premise have no probative value. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim). See also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, the Board finds that this evidence is not probative to warrant a grant of the claim and it outweighed by the January 2013 VA medical opinion. In August 2006, the Veteran requested a letter from a VA physician to support his claim for service connection for arthritis of the left hand, stating that his bilateral hand and wrist pain began in July 1990. The VA physician interviewed the Veteran via telephone and reviewed VA treatment records and examination reports. She concluded that there were no medical records to support the Veteran's claim, noting that he did not seek medical treatment for hand or wrist pain during active service. She noted that the Veteran did discuss his pain with Dr. P.R., a co-worker, when he was a nurse in a medical unit at Clark Air Force Base, and that Dr. P.R. corroborated his contention that his hand pain began in July 1990. However, due to the lack of medical records to support his claim, the doctor stated she was unable to write a letter in support of his claim for service connection. This medical statement has no probative value because the VA physician did not indicate that the service treatment records were reviewed and it does not include any opinion as to the relationship between the claimed condition and service. For the reasons and bases discussed above, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for left hand arthritis as a presumptive disease and on a direct basis, and the claim must be denied. ORDER Service connection for left hand arthritis is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs