Citation Nr: 1322260 Decision Date: 07/11/13 Archive Date: 07/18/13 DOCKET NO. 06-34 443 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for chronic headaches, to include as secondary to service-connected rheumatoid arthritis of multiple joints. 2. Entitlement to service connection for gastrointestinal (GI) and esophageal disorders, to include as secondary to service-connected rheumatoid arthritis of multiple joints. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1953 to October 1959. These matters come before the Board of Veterans' Appeals (Board) on appeal from September 2005 and November 2007 rating decisions of the Department of Veterans Affairs (VA) Regional Offices (ROs) in San Diego, California and Montgomery, Alabama respectively. Jurisdiction over the claim is currently with the RO in Montgomery, Alabama. In January 2011, the Veteran testified at a Travel Board hearing before the undersigned. The Veteran was provided an opportunity to set forth his contentions at the hearing. The record reflects that at this hearing the undersigned set forth the issues to be discussed at the hearing, focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required to help substantiate the claims. These actions satisfied the duties a Veterans Law Judge has to explain fully the issue and to suggest the submission of evidence that may have been overlooked. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010) (holding that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board). A copy of the hearing transcript has been associated with the claims folder. The Board has remanded the matters on appeal in July 2011, December 2011, and in November 2012 to the RO via the Appeals Management Center (AMC) in Washington DC to obtain additional evidence. Specifically, in July 2011, the Board instructed the RO/AMC to provide the Veteran with a VA examination to determine the nature and etiology of his claimed chronic headache and GI/ esophageal disorders, to include consideration that either disorder was caused or worsened by his service-connected disability. The Board also asked that a VA medical opinion be obtained on whether the Veteran's service-connected disability precluded employability. Another VA examination was sought in December 2011 and an addendum VA medical report was sought in November 2012 to address the inadequacies of the previous medical conclusions. As those actions have been completed, the case has properly been returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). 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. 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). FINDINGS OF FACT 1. The Veteran's current diagnosed chronic headaches disorder was not incurred or aggravated in military service, nor is not proximately due to or the result of his service-connected rheumatoid arthritis, to include medication taken to treat his rheumatoid arthritis. 2. The Veteran's current diagnosed GI and esophageal disorders were not incurred or aggravated in military service, nor is not proximately due to or the result of his service-connected rheumatoid arthritis, to include medication taken to treat his rheumatoid arthritis. 3. The Veteran is service connected for rheumatoid arthritis, rated as 40 percent disabling, and for tinnitus, rated as 10 percent disabiling. The Veteran does not meet the combined schedular requirements for TDIU. 4. The Veteran's service-connected disabilities, standing alone, are not of such severity so as to preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for chronic headaches have not been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for entitlement to service connection for GI and esophageal disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 3. The criteria for entitlement to TDIU have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16, 4.18, 4.19, 4.25 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159, provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim, defined to include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In the case at hand, the record reflects that the RO provided the Veteran with the notice required under the VCAA and under Dingess by letters mailed in June 2005, November 2006, and July 2007. The RO adjudicated the Veteran's claims in the first instance in September 2005 and November 2007. The Veteran filed a timely appeal as to these rating decisions. Accordingly, with respect to VCAA notice, there is no prejudice to the Veteran in the Board's proceeding with the issuance of a decision on the merits as to his service-connection claims and TDIU claim. Concerning the VA's duty to assist, the Board notes that the Veteran's service treatment records, his lay statements of argument, and VA treatment records have been obtained. Pertinently, the Veteran has not indicated that any other VA treatment reports relevant to his hearing loss claim currently exist, nor has he requested that the VA attempt to obtain any other private treatment records. Pursuant to the Board's July 2011, December 2011, and November 2012 remand directives, VA examinations were conducted in August 2011 and February 2012, and an addendum with medical conclusions was obtain in January 2013. The Board observes that collectively the findings contained in these reports are more than adequate to adjudicate the Veteran's claims. The examination reports reflects that the examiner reviewed the Veteran's past medical history, recorded his current complaints, conducted an appropriate examination, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. In the January 2013 addendum report, the examiner noted that she reviewed the entire claims folder, including the findings from the August 2011 and February 2012 VA examination reports, and the examiner provided an opinion addressing whether the Veteran's claimed disorders were related to his period of service, to include as secondary to his service-connected disability. The January 2013 VA examiner also provided a medical opinion on the Veteran's ability to maintain and obtain substantially gainful employability because of the severity of his service-connected disabilities. The Board therefore concludes that the 2011, 2012 and 2013 reports, considered together, are adequate for rating purposes. See 38 C.F.R. § 4.2; Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions with respect to the issues on appeal have been met. 38 C.F.R. § 3.159(c)(4). In short, the Board has carefully considered the provisions of the VCAA, in light of the record on appeal and, for the reasons expressed above, finds that the development of these issues has been consistent with said provisions. The Board is satisfied that any procedural errors in the originating agency's development and consideration of the claims were insignificant and nonprejudicial to the Veteran. The Veteran has been accorded ample opportunity to present evidence and argument in support of his claim. See 38 C.F.R. § 3.103. He has retained the services of a representative, and testified before the undersigned at the November 2011 hearing. Accordingly, the Board will address the claims on appeal. 2. Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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. 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. See 38 C.F.R. § 3.303(b). The chronicity provision of 38 U.S.C.A. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Certain chronic diseases, although not shown in service, may be presumed to have incurred in or aggravated by service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. To prevail on the issue of service connection, there must be (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 current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, a disability that is proximately due to or the result of a service-connected injury or disease shall be service connected. 38 C.F.R. § 3.310. When service connection is thus established for a secondary condition, the secondary condition shall be considered part of the original condition. Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists, and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. A disability which is aggravated by a service-connected disorder may be service connected, but compensation is only available for the degree to which that condition was made worse by the service-connected condition - only to the degree that the aggravation is shown. 38 C.F.R. § 3.310. In such a situation, VA laws require that the medical evidence must show a baseline level of severity of the nonservice-connected disease or injury, which is established by medical evidence created before the onset of aggravation. Id. The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. In this case, the Veteran asserts entitlement to service connection for chronic headaches and GI/esophageal disorders. He claims his GI symptoms and headaches had an onset during his period of service and were aggravated by the medications he takes for his service-connected rheumatoid arthritis. The Veteran contends that he has continuously sought treatment for chronic pain in multiple joints, which included several different medications, since 1961. He further reports that his multiple joint pains were exacerbated by injuries sustained in a 1980 motor vehicle accident. He alleges that due to the amount of medications that he takes is the primary cause of his GI/esophageal disorders. He further contends that as a result of the severe pain, he experiences chronic headaches. See July 2005 statement in support of the case; see also July 2011 Travel Board hearing transcript. A review of the Veteran's service treatment records shows that he was treated for rheumatoid arthritis of multiple joints from March 1955 until his medical retirement in October 1959. These records show that the Veteran was hospitalized for five months from March 1955 to July 1955 to treat rheumatoid arthritis. He was initially prescribed salicylates up to 20 grains four times a day, but it was decreased to 15 grains four times a day because of complaints of tinnitus. He was taking approximately eight aspirin a day during his hospitalization. The Veteran continued to complain of discomfort and he was prescribed cortisone from 25 to 50 milligrams four times a day, with moderate relief. The records show that he complained of epigastric heart burn pain with increased dosage. His cortisone prescription was subsequently decreased and discontinued. In July 1955, the Veteran was determined to be unfit for military service due to his rheumatoid arthritis and he was placed on temporary duty retirement. He continued to be prescribed salicylates to treat rheumatoid arthritis and he reportedly took 12 to 15 aspirin per day to treat the pain associated with his rheumatoid arthritis. The Veteran underwent a periodic service medical examination and history in February 1958. The Veteran complained that in the past year, he had experienced excessive gas pain for several months. The examiner noted that the Veteran had a recent history of parasitis, and he was treated with medication and the parasitis resolved, but the records continued to show that he complained of gas symptoms. It was also noted that when the Veteran was taking 200 milligrams of cortisone a day in 1955, he had undergone an x-ray GI series, which revealed evidence of duodenal ulcer. In February 1958, the Veteran underwent another upper GI series in conjunction with his complaints of excessive gas, but there was no evidence of ulcers or any abnormality of the esophagus, hiatus or stomach. There was evidence of deformity of the duodenal bulb without demonstration of ulcer crater. The report of the February 1958 periodic examination shows that the Veteran was assessed with functional GI complaints, and his abdomen had prominent borborygmi. A September 1959 service orthopedic consultation report shows that the Veteran continued to take salicylates of 50 to 60 milligrams to treat his rheumatoid arthritis. During a September 1959 periodic service examination, he received normal head, mouth, throat, abdomen, viscera, and neurologic evaluations. The Veteran was medically separated from active service in October 1959. None of the Veteran's service treatment records shows complaints, treatment, or diagnosis for any headache-related disorders. An April 1960 private treatment record notes that the Veteran had a history of rheumatoid arthritis, for which he is currently on disability, and he had probable esophagitis. However, subsequent post-service treatment records dated in the 1960's, do not show that the Veteran was being prescribed medication to treat rheumatoid arthritis symptomatology, or show that the Veteran complained of headaches, GI, esophageal or stomach disorder. The report of a private June 1973 GI series shows evidence of a small peptic ulcer in the apex of the duodenal bulb with deformity of the bulb, but there was no evidence of lesions in the esophagus or stomach, or delay in the passage of barium through the upper gastrointestinal tract. The peptic ulcer disease, duodenal was assessed as quiet. A subsequent private July 1973 upper GI series shows no abnormalities were observed in the esophagus, or evidence of a hiatus hernia, and the previous peptic ulcer crater could no longer be identified. Private treatment records in the 1980's show that the Veteran sustained injuries to his neck and back from a work-related motor vehicle accident in August 1980. These private treatment records show that he was treated for significant pain associated with his neck, back and shoulder problems. He was diagnosed with degenerative changes in the lumbar spine and in the cervical spine, cervical spine neurologic involvement, fibromyitis, and fibromyalgia. These records note that the Veteran complained of chronic headaches that involved radiating pain from his shoulder and neck. In several of these records, it is noted that the Veteran had a history of rheumatoid arthritis in service, but none of them show that the Veteran was being prescribed medication to treat rheumatoid arthritis. Although it is noted that he continued to seek treatment from his private rheumatologist, a June 1991 statement from the Veteran's rheumatologist, Dr. G.D., shows that he was treating the Veteran for a current diagnosis of fibromyalgia,which was manifested by severe aches and pains all over his body following a 1981 motor vehicle accident. Dr. G. stated that it was possible that the Veteran's fibromyalgia was triggered by the 1980 motor vehicle accident given that the onset of his symptoms followed that accident. When the Veteran was hospitalized in June 1987 to treat a hepatitis B infection, he underwent a private upper GI series, which revealed evidence of hypertrophic folds in the stomach and spasms in the gastric antrum, but no other abnormalities. There was no evidence of an ulcer or anything to suggest a tumor. The report of a June 1987 CT scan of the abdomen revealed no abnormalities, other than evidence of generalized slight thickening of the gallbladder that suggested findings of chronic cholecystitis. Medical records and other documents associated with the Veteran's 1991 application for Social Security Administration (SSA) disability benefits shows that the Veteran had been regularly seeking treatment from his private rheumatologist, chiropractor, and neurosurgeon. The Veteran is currently receiving SSA disability benefits for severe degenerative disc disease and fibromyalgia. In multiple private medical statements from the Veteran's chiropractor to SSA, the chiropractor noted that he has been treating the Veteran for chronic symptoms of severe suboccipital headaches, neck pain, and upper dorsal pain and spasms since 1989. It was noted that the Veteran had an eleven year history of this symptomatology following repeated automobile accidents that were related to his work as a police officer. See statements from P.L.S., D. C., dated in January 1990, September 1990, November 1990, and September 1991. An undated private treatment noted from the Veteran's neurosurgeon shows that the Veteran complained of "neck pain with catches and popping in his neck which gives him headaches." The Veteran was assessed with muscular contraction headaches secondary to tension and cervical degenerative disc disease. A February 2004 private report shows that diagnostic testing revealed evidence of esophagitis in the total esophagus. In a June 2005 private medical statement, the Veteran's treating physician, Dr. J. T. C., noted that the Veteran had been seen several times a month since 1961 to treat his multiple medical conditions. The Veteran's medical problems included chronic headaches, reflux esophagitis, anxiety disorder, as well as severe osteoarthritis and fibromyalgia. The Veteran had received different medications and injections, without much relief, and the Veteran was referred to a rheumatologist for further evaluation of his arthritis and fibromyalgia. The Veteran later reported that he sought treatment from Dr. C. until 2001, which included treatment with corticosteroid injections in the back, hips, and arms on several occasions. VA treatment records starting in 2005 show that the Veteran sought treatment for arthritis of multiple joints. It was noted that the Veteran had previously sought treatment from a private rheumatologist. A November 2005 VA treatment note shows that the Veteran's sulfasalazine prescription should be assessed and may need to be increased if it was not effective. In an April 2006 VA rheumatology consultation note, it was noted that the Veteran had regularly seen his private rheumatologist, Dr. G., until 1994, and the Veteran had not seen a rheumatologist since then. The treating VA physician questioned whether the Veteran's rheumatoid arthritis was active. In a July 2008 VA rheumatology consultation note, it was noted that the Veteran had not been treated by a rheumatologist since 2006. He continued to take pain medications and aspirin to alleviate his chronic pain. It was noted that he was intolerant to sulfasalazine and he had a history of GERD and candida esophagitis. His disease modifying antirheumatic drug (DMARD) therapy was discontinued at that time. Subsequent VA treatment records show diagnoses of polymalgia rheumatic, scoliosis, osteoarthritis, degenerative disc disease and osteoporosis. Pursuant to the Board's July 2011 remand directives, the Veteran underwent a VA examination in August 2011 to determine the nature and etiology of his claimed chronic headache and GI/esophageal disorders. The August 2011 VA examination report shows that the VA examiner reviewed the claims folder, and recorded the Veteran's reported medical history and the findings from clinical evaluation. The examiner diagnosed the Veteran with tension headaches, GERD, and status-post inguinal hernia. The August 2011 VA examiner opined that none of these diagnoses were "caused by or related to service or service connected condition." The examiner, however, did not render an opinion as to whether any found condition was "aggravated by" the Veteran's service-connected rheumatoid arthritis beyond the natural progression of the disease. The Board remanded the matters in order so that the Veteran could be afforded another VA examination in February 2012 to consider the matter of aggravation. The February 2012 VA examination report shows that the VA examiner reviewed the claims folder, and recorded the Veteran's reported medical history and the findings from clinical evaluation. The February 2012 VA examiner diagnosed the Veteran with muscle tension headaches and gastroesophageal reflux disease (GERD) with small sliding hiatus hernia. As to the etiology of the muscle tension headaches, the February 2012 VA examiner opined that it "is not caused by, related to or aggravated beyond the natural progression by his service-connected rheumatoid arthritis, to include medications taken in connection with rheumatoid arthritis." In support of this medical statement, the examiner noted that the Veteran's service treatment records were silent for headaches, headaches were diagnosed post-service, and that they were most likely caused by and related to non-service-connected cervical degenerative disc disease. As to the etiology of the Veteran's GERD with small sliding hiatus hernia, the February 2012 VA examiner again opined that it "is not caused by, related to or aggravated beyond the natural progression by his service-connected rheumatoid arthritis, to include medications taken in connection with rheumatoid arthritis." In her rationale, she again explained that the Veteran's service treatment records were silent for GERD with small sliding hiatus hernia, it was acquired and diagnosed 32 years post-service, and 1958 and 1987 upper GI series were silent for GERD and hiatus hernia identified. The Board considered both of the February 2012 VA examiner's statements to be simply conclusory and insufficient to rational to support her medical conclusion that the Veteran's rheumatoid arthritis, to include the medication, did not aggravate his chronic headache or GI/esophageal disorders. The Board remanded the matters again to obtain a January 2013 addendum report from the February 2012 VA examiner that adequately addresses the question of etiology of the Veteran's claimed disorders. In the January 2013 addendum, the February 2012 VA examiner reviewed the entire claims folder, including the February 2012 VA examination report. The VA examiner confirmed diagnoses of muscle tension headaches and GERD with small sliding hiatus hernia. Regarding the Veteran's chronic headache disorder, the VA examiner opined that it was less likely than not that the diagnosed disorder was incurred in or caused by the Veteran's military service, to include excessive use of aspirin. In support of her medical conclusion, the VA examiner noted that a review of the Veteran's service treatment records and immediate post-service treatment records failed to show complaints for headaches. Rather, the post-service medical records from the Veteran's treating neurosurgeon show the Veteran's headache disorder was thought to be associated with his cervical spine degenerative disc disease and associated tension. The examiner concluded that the available objective medical evidence of record showed that the chronic headaches were likely caused and aggravated by the work-related 1980 automobile accident. The examiner noted that a review of the medical literature show that neck pain and cervical muscle tension commonly lead to headache disorders. The VA examiner further opined that the Veteran's chronic headache disorder was not proximately caused or aggravated by his service-connected rheumatoid arthritis, to include medications taken to treat his rheumatoid arthritis. The examiner noted that none of the available objective medical evidence in the service treatment records or post-service treatment records suggested that the Veteran's headache disorder was caused or aggravated by his rheumatoid arthritis. With respect to the Veteran's GERD with small sliding hiatus hernia, opined that it was less likely than not that the diagnosed disorder was incurred in or caused by the Veteran's military service, to include inservice gastrointestinal complaints and excessive use of aspirin. The examiner noted that the in-service upper GI series in 1955 and 1958 and the post-service upper GI series in 1987 did not reveal evidence of GERD with small sliding hiatus hernia. The Veteran's current diagnosis was not shown by diagnostic testing until the August 2011 upper GI series, which came more than five decades after the Veteran's separation from active duty. The VA examiner further opined that the Veteran's GERD with small sliding hiatus hernia was not proximately caused or aggravated by his service-connected rheumatoid arthritis, to include medications taken to treat his rheumatoid arthritis. The examiner noted that none of the available objective medical evidence in the service treatment records or post-service treatment records suggested that the Veteran's headache disorder was caused or aggravated by his rheumatoid arthritis. In this case, the Veteran seeks entitlement to service connection for chronic headaches and GI/esophageal disorders. Again, the Board notes that in order to support an award of service connection on direct basis there must be evidence of a current disability, in-service incurrence or aggravation of a disease or injury; and medical nexus between the claimed in-service disease or injury and the current disability. See Hickson, 12 Vet. App. at 253. With respect to element (1), the medical evidence of record demonstrates that the Veteran current diagnoses of muscle tension headaches and GERD with small sliding hiatus hernia. See August 2011 and February 2012 VA examination reports, as well as VA treatment records. It is clear that element (1), current disability, is satisfied with respect to both claims. With respect to element (2), in-service incurrence or aggravation of a disease or injury, the Board will address the matters separately. The Veteran's service treatment records do not document any treatment or complaints of headaches, let alone findings indicative of muscle tension headaches. At the time of a September 1959 examination periodic examination prior to his separation, the Veteran received normal head and neurologic evaluations, and there was no indication of any headache problems. The Board observes that the evidence of record does not show that the Veteran was diagnosed with a chronic headaches disorder in service, at separation, or until two decades after his discharge from service. 38 C.F.R. §§ 3.303, 3.307, 3.309. The Veteran's service treatment records do show that that he complained of epigastric heart burn pain and excessive gas in 1955, and he was assessed with functional gastrointestinal complaints in 1958, despite the normal findings on upper GI series in March 1955 and February 1958. The June 1973 private GI series showed evidence of a duodenal ulcer, but that was no longer visible a month later on the July 1973 GI series. Neither of the 1973 upper GI series showed abnormalities in the esophagus or stomach, or evidence of a hiatus hernia. Also, the 1987 upper GI series was negative for abnormalities in the stomach or esophagus. There is no medical evidence showing that the Veteran's current GERD with small sliding hiatus hernia existed during service or until decades after his separation from service. See 38 C.F.R. §§ 3.303, 3.307, 3.309. With respect to in-service injury, the service treatment records do show that the Veteran took large amounts of aspirin while he was hospitalized from March 1955 to July 1955 (approximately eight aspirin daily) and he continued to take aspirin up to 15 aspirin per day to treat the pain associated with his rheumatoid arthritis during the remainder of his service. During his hospitalization, he was also treated with up 200 milligram per day of cortisone, and he was subsequently prescribed salicylates to treat his rheumatoid arthritis. The Veteran is also in receipt of service connection for rheumatoid arthritis. Element (2), an in-service injury, has been satisfied. With respect to element (3), nexus or relationship, there is no favorable medical nexus opinion of record that supports a direct medical link between the current diagnoses of muscle tension headaches and GERD with small sliding hiatus hernia and the Veteran's period of service, to include excessive aspirin use or inservice gastrointestinal complaints. Also, there is no favorable medical nexus opinion of record that supports a secondary medical link between the Veteran's current diagnosed disorders and his service-connected rheumatoid arthritis, to include medication taken to treat his rheumatoid arthritis. Rather, the medical conclusions of record show that the Veteran's muscle tension headaches are likely secondary to his non-service connected cervical spine disorders. The Veteran's treating neurosurgeon first assessed the Veteran's chronic headaches disorder as secondary to cervical spine degenerative disc disease and associated tension. The February 2012 VA examiner in the January 2013 addendum concluded that the Veteran's muscle tension headaches and GERD with small sliding hiatus hernia was incurred in or caused by his period of service, to include excessive use of aspirin or proximately caused or aggravated by his service-connected rheumatoid arthritis, to include medications to treat his disorder. The VA examiner based her medical conclusions on a review of the claims folders, and the findings from clinical evaluation, and she provided rational statements in the January 2013 addendum that supported her conclusions. The VA examiner's medical opinions heavily weighs against the Veteran's claims that his diagnosed muscle tension headaches and GERD with small sliding hiatus hernia were related to his in-service excessive use of aspirin or medication to treat his rheumatoid arthritis or were aggravated by his service-connected rheumatoid arthritis, to include medication to treat his rheumatoid arthritis over the years. No medical opinion of record is contrary to the findings of the VA examiner in the February 2012 VA examination report with January 2013 addendum. The Veteran has been accorded ample opportunity to furnish medical and other evidence in support of his service-connection claims, and against the reasoned conclusions of the VA examiner; he has not done so. See 38 U.S.C.A. § 5107(a) (it is a claimant's responsibility to support a claim for VA benefits). The Board has considered the Veteran's lay assertions that his muscle tension headaches and/or GERD with small sliding hiatus hernia is etiologically related to his inservice use of aspirin and medication to treat his service-connected rheumatoid arthritis. The Board finds, however, that the lay assertions in this matter are afforded little probative weight in the absence of evidence that the lay speaker has medical training that can provide the expertise to render opinions about medical matters. See Bostain v. West, 11 Vet. App. 124, 127 (1998). Where the determinative issue involves a medical opinion, there must be competent medical evidence to the effect that the claim is plausible. Id. Notably, the question of whether the Veteran's is muscle tension headaches and/or GERD with small sliding hiatus hernia were caused or aggravated by in-service use of aspirin and medication to treat his service-connected rheumatoid arthritis can only be answered based on medical expertise that cannot be identified by a lay person. Jandreau v. Nicholson, 492 F.3d 1372, 1377(Fed. Cir. 2007). To the extent, the lay arguments contain opinions as to the medical etiology of the Veteran's claimed disorders; this is simply not competent or persuasive evidence. As noted above in the legal criteria above, under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third service-connection element for certain chronic diseases, including uclers, is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Indeed, the Veteran has asserted at times during the appeal period that he has experienced GI and esophageal problems since his service period to the present day. The Veteran contends that he continued to experience GI and esophageal problems since his period of service and his symptoms were aggravated by the medication he take to treat his rheumatoid arthritis. Indeed, the Veteran is competent to describe his in-service experiences and observations of pain symptomatology, and his service treatment records confirm that he sought treatment for espigastric pain and excessive gas in March 1955 and February 1958, and despite the lack of diagnostic evidence, he was assessed with functional gastrointestinal complaints in February 1958. See 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). Also, the April 1960 private treatment note contains a finding of probable esophagitis, albeit none of the subsequent post-service treatment records shows any GI or esophageal complaints until more than a decade after his separation from service. Competency of evidence, however, differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter 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, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Court has made clear that the Board cannot determine that competent lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Veteran complaints are consistently recorded in the medical records in service as well as after his separation, and the Board has no reason to doubt the credibility of the Veteran's statements. See Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). However, here, the more probative medical evidence has ruled out a medical link between the Veteran's current diagnosed GERD with sliding hiatal hernia and the in-service use of aspirin as well as the in-service and post-service medication to treat his rheumatoid arthritis. This VA medical opinion is based upon a review of the medical evidence of record, which included the Veteran's reported history, as well as the examiner's medical expertise. Accordingly, element (3), a nexus or relationship between the current diagnosed disorders and injury in service or service-connected disability, has not been satisfied, and the Veteran's service-connection claims fails on this basis. The benefit of the doubt rule is not for application because the evidence is not in relative equipoise. 3. TDIU Claim VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his or her education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Under the applicable regulations, benefits based on individual unemployability are granted only when it is established that the service- connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. Under 38 C.F.R. § 4.16, if there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) Disabilities resulting from common etiology or a single accident, (3) Disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) Multiple injuries incurred in action, or (5) Multiple disabilities incurred as a prisoner of war. Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the Veteran's background including his or her employment and educational history. 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular total disability rating for compensation purposes based on individual unemployability in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. In this case, the Board notes that the Veteran is service connected for rheumatoid arthritis of multiple joints, rated as 40 percent disabling; and for tinnitus, rated as 10 percent disabling. As such, his combined rating is 50 percent according, and his service-connected disabilities do not meet the schedular percentage rating standards for TDIU. 38 C.F.R. § 4.16(a). Nevertheless, the Board must consider whether the evidence warrants referral to the appropriate VA officials for entitlement to a total disability rating for compensation purposes based on individual unemployability on an extraschedular basis under the provisions of 38 C.F.R. §4.16(b). See Bowling, 15 Vet. App. at 6. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough; the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Here, the Veteran asserts that he is unable to work because of the severity of his service-connected disabilities. In particularly, he contends that he is unemployable mainly because of the severity of his service-connected rheumatoid arthritis of multiple joints. However, having reviewed the record, the Board finds that the preponderance of the evidence weighs against finding that he is unable to secure or maintain substantially gainful employment solely due to his service-connected disabilities. Initially, the Board observes that the Veteran has not asserted that he is unemployable in any part because of his service-connected tinnitus. Rather, he has attributed his unemployability primarily to his service-connected rheumatoid arthritis. That being said, the report of an August 2011 VA audiology examination report shows that Veteran complained that his tinnitus makes him nervous at time and occasionally keeps him awake at night. The currently assigned 10 percent evaluation is the maximum schedular rating available for service-connected tinnitus. See 38 C.F.R. § 4.87, Diagnostic Code 6260. In addition to the Veteran's service-connected rheumatoid arthritis and tinnitus, the medical evidence shows that Veteran has also been diagnosed with osteoarthritis, degenerative joint disease, fibromyalgia and fibrositis. The Veteran was in major motor vehicle accidents (MVAs) after service in the 1980s, further causing joint impairment. Indeed, the Veteran is currently receiving the Social Security Administration (SSA) disability benefits for severe degenerative disc disease and fibromyalgia, but not for rheumatoid arthritis. This SSA benefits award was based in large part on several medical statements from the Veteran's treating medical providers that he was no longer able to work because of the pain associated with his non-service connected cervical spine and lumbar spine degenerative disc disease. The Veteran was afforded VA examinations specifically for his rheumatoid arthritis in July 2005, July 2007, July 2009, and August 2011. Medical providers, throughout time, have differed in opinion as to whether the Veteran's rheumatoid arthritis is "active." The July 2005 VA examiner found no evidence of active rheumatoid arthritis, but instead diagnosed the Veteran with "polyarthritis" and degenerative joint disease. In contrast, in July 2007, the examiner did opine as finding evidence consistent with active rheumatoid arthritis. The July 2009 VA examiner, a physician's assistant, diagnosed the Veteran with "service-connected rheumatoid arthritis" with a functional limitation of mild to moderate. However, the August 2011 VA examiner found no clear evidence of active rheumatoid arthritis and merely diagnosed rheumatoid arthritis by history, finding mild limitations attributable to rheumatoid arthritis. Pursuant to the Board's November 2011 remand directives, the Veteran was afforded with VA examinations in order to evaluate the severity of his service-connected rheumatoid arthritis. The report of the February 2012 VA examination report shows that the examiner reviewed the claims file and recorded the findings from clinical evaluation. The examiner noted that the Veteran reported that he was uncertain when he was last seen or treated for active rheumatoid arthritis. The Veteran currently complained of back, bilateral knee and right shoulder problems. The VA examiner found that there was no objective evidence of rheumatoid arthritis deformity in the Veteran's hands, knees or back, and instead diagnosed the Veteran with other various orthopedic disorders. Ultimately, based on the findings from clinical evaluation, the February 2012 VA examiner concluded that the Veteran's service-connected rheumatoid arthritis was inactive and not on treatment. She explained that the "[p]reponderance of medical evidence (clinical and radiologic findings) do not support active [rheumatoid arthritis]." The February 2012 VA examiner further opined that the Veteran's service-connected rheumatoid arthritis alone was not severe enough so as to render him unemployable. Rather, the VA examiner felt that the Veteran's advanced age and other serious orthopedic medical conditions likely caused him occupational impairment. In March 2013, pursuant to the Board's November 2012 remand directives, a VA medical opinion was obtain that addressed the effect of the Veteran's service-connected rheumatoid arthritis on his employability. The March 2013 VA medical report shows that the examiner reviewed the claims folders, including the reports of the February 2012 VA examination. The VA examiner concluded that the Veteran's service-connected disability alone does not preclude the Veteran from obtaining or maintaining substantial gainful moderate or regular employment. The Board acknowledges the Veteran's contentions that he is unable to work due to his service-connected rheumatoid arthritis. However, the most probative medical evidence of record does not support these contentions. Lay persons can attest to factual matters of which they had first- hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). While the Veteran is competent to report what comes to him through his senses, he does not have medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469- 470 (1994). Here, the Veteran described his limitations caused by his service-connected rheumatoid arthritis, and the Board acknowledges that his statement in that regard is competent and of some probative value. However, the Board also notes that the complexity of his medical history and variety of health problems create some limitation as to his ability to distinguish to what degree those limitations are a result of his service-connected disabilities and to what degree those limitations are attributable to his nonservice-connected medical conditions such as degenerative arthritis of the cervical and lumbar spine with neurologic involvement that also impacts his ability to work. Consequently, the Board ultimately places more weight on the VA opinions regarding whether the Veteran is unemployable due solely to service-connected conditions. The Board finds that the most probative medical evidence of record on the matter is against a finding that the Veteran is unemployable due to his service-connected disabilities so as to warrant referral of the issue of entitlement to TDIU on an extraschedular basis. In summary, while the Board does not doubt that the Veteran's service-connected disabilities have some effect on his employability, the weight of the evidence does not support his contention that his service-connected disabilities are of such severity so as to preclude his participation in any form of substantially gainful employment. The Board believes that the symptomatology associated with the service-connected disabilities is appropriately compensated via the combined 50 percent rating which is currently assigned. Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a), 4.1. Indeed, 38 C.F.R. § 4.1 specifically states: "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992) and Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Thus, the Board finds that the RO's decision not to refer this issue consideration of TDIU was correct. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for chronic headaches is denied. Entitlement to service connection for GI and esophageal disorders is denied. Entitlement to TDIU is denied. ____________________________________________ A. C. MACKENZIE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs