Citation Nr: 1322795 Decision Date: 07/17/13 Archive Date: 07/24/13 DOCKET NO. 03-06 318 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for a low back disability. REPRESENTATION Appellant represented by: Sean A. Ravin, Attorney WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The Veteran served on active duty from July 1965 to July 1968, a portion of which represented service in the Republic of Vietnam. This case originally came before the Board of Veterans' Appeals (Board) on appeal of a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In March 2005, the Veteran offered testimony before the undersigned Veterans Law Judge. A transcript of that hearing is contained in the Veteran's claims folder. In a decision of May 2005, the Board denied entitlement to service connection for a low back disability. The Veteran subsequently appealed that decision to the United States Court of Appeals for Veterans Claims (Court), which, in a December 2006 Order, vacated the Board's May 2005 decision, and, in so doing, remanded the Veteran's case to the Board for action consistent with a November 2006 Joint Motion. In July 2007, the Veteran's case was once again remanded for additional development. Following that development, the Board, in a decision of February 2008, once again denied entitlement to service connection for a low back disability. That decision was again appealed to the United States Court of Appeals for Veterans Claims (Court), which, in a May 2010 Memorandum Decision, vacated the Board's February 2008 decision, and, in so doing, remanded the Veteran's case to the Board for adjudication consistent with the Memorandum Decision. In November 2010, the Veteran's case was once again remanded to the RO for additional development. Following completion of that development, the Board, in a decision of November 2011, again denied entitlement to service connection for a low back disability. That determination was once again appealed to the United States Court of Appeals for Veterans Claims (Court), which, in an August 2012 Order, vacated the Board's November 2011 decision, and, in so doing, remanded the Veteran's case to the Board for action consistent with an August 2012 Joint Motion. The case is now, once more, before the Board for appellate review. FINDING OF FACT A chronic low back disability is not shown to have been present in service, or for many years thereafter, nor is it the result of any incident or incidents of the Veteran's period of active military service, including an inservice fall. CONCLUSION OF LAW A chronic low back disability was not incurred in or aggravated by active military service, nor may degenerative joint disease (i.e. osteoarthritis) be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) includes enhanced duties to notify and assist claimants for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements under the VCAA essentially require that VA notify a claimant of any evidence necessary to substantiate his claim, as well as the evidence that VA will attempt to obtain, and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) [addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) (2012)]. As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VA's notice requirements apply to all five elements of a service connection claim: Veteran status, existence of a disability, connection between the Veteran's service and disability, degree of disability, and effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant prior to the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may nonetheless be satisfied where any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this case, in correspondence of December 2004, the Veteran was informed of the evidence required to substantiate his claim and of his and VA's respective duties for obtaining evidence. While it does not appear that the Veteran was specifically informed of the way VA assigns disability ratings and effective dates in accordance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), given that the Veteran's claim is being denied, no disability or effective date is being assigned, and the Veteran is thereby not prejudiced by this omission. Also, although the December 2004 letter was sent after the initial RO decision in this matter, the Board finds that this error was not prejudicial. In that regard, the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, and has been given ample time to respond to all VA determinations. Moreover, the Veteran's case was readjudicated in a November 2007 Supplemental Statement of the Case following the provision of VCAA notice. Under the circumstances, the Board finds that sufficient VCAA notice has been provided to the Veteran. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the Veteran's claim. Relevant medical evidence associated with the claims file consists of the Veteran's service treatment records, private treatment records, VA treatment records, and reports of VA examinations. Also of record and considered in connection with the Veteran's appeal is the transcript of a March 2005 Board hearing, along with various written statements provided by the Veteran, his accredited representative, his wife, and his friends. Under the circumstances, the Board is of the opinion that no further RO action is required prior to appellate consideration of the Veteran's claim. Moreover, during the March 2005 hearing, the undersigned explained the issue on appeal and asked questions designed to elicit evidence that may have been overlooked with regard to the claim. These actions provided an opportunity for the Veteran and his then representative to introduce material evidence and pertinent arguments in compliance with 38 C.F.R. § 3.103. The Veteran's attorney has argued that additional examination is needed, in part as the previous examiner discounted the lay statements submitted. As will be set forth in greater detail below, it is concluded that the examinations on file are adequate for purposes of adjudication and the lay statements will be discussed and evaluated in detail. Factual Background Service treatment records disclose that, at the time of a July 1965 service entrance examination, the Veteran's spine was within normal limits. In May 1968, the Veteran was noted to have hit his right leg on a rock while jumping across a stream. Following that incident, the Veteran complained of a laceration to his right leg. Subsequent physical examination showed no swelling, though there was pain surrounding the local area, as well as the Veteran's shin bone. The Veteran was subsequently referred to a local hospital for radiographic studies, which proved to be negative. Significantly, at no time were there any recorded complaints of back pain. The Veteran was subsequently given light duty for 48 hours. As of the time of a service separation examination in July 1968, the Veteran's spine was once again found to be within normal limits. Significantly, in a report of medical history accompanying that separation examination, the Veteran denied any problems with recurrent back pain. VA treatment records dated in January and February 2001 show that the Veteran was hospitalized following complaints of hip and back pain. At that time, the Veteran gave a one year history of low back pain. Elsewhere, at admission to the emergency room, the Veteran indicated that he had experienced problems with right hip pain for approximately two to three months, and that hip pain had recently become significantly worse. Computerized tomography (CT) was significant for scattered degenerative changes, with spinal canal stenosis at the level of the fourth lumbar vertebra and first sacral segment. The February 2001 discharge diagnosis was lumbar disc disease. Medical records dated subsequent to January 2001 show continued treatment for low back pain. In that regard, in March 2001, a VA magnetic resonance imaging (MRI) scan of the lumbar spine yielded a diagnostic assessment of focal disc protrusion centrally at the level of the fourth lumbar vertebra and first sacral segment, with accompanying mild spinal stenosis. June 2001 electromyographic/nerve conduction velocity testing was normal with the exception of mild sural neuropathy. At the time of an August 2001 VA Agent Orange examination, it was noted that the Veteran's chief complaint was of low back pain, which had reportedly been getting worse since early that year. When questioned, the Veteran indicated that he thought his low back problem was related to his Army duties or Army service. On musculoskeletal examination, there was evidence of low back pain with some degenerative disc protrusion at the level of the fourth lumbar vertebra and first sacral segment, in conjunction with mild spinal stenosis. Reportedly, the Veteran had been receiving medical management, since there was no evidence of any significant neurological loss. Additionally noted was that the Veteran had been receiving physiotherapy, and utilizing a back brace. Examination of the Veteran's back showed evidence of slight tenderness at the lumbosacral area with limited flexion. Neurological examination was significant for the presence of decreased sensation on the right side. The pertinent diagnosis was degenerative joint disease of the lumbosacral spine with slight neuropathy. Subsequent VA medical records covering the period from September 2001 to September 2002 show ongoing treatment for low back disability. Reportedly, the Veteran had been receiving some physical therapy, but, apparently, no pain relief with treatment. Additionally noted was that the Veteran continued to receive medication for pain. Private medical records covering the period from March to August 2002 show ongoing evaluation and treatment of low back pain, including medication for pain and a muscle relaxant. Significantly, the Veteran reported a 30 year history of low back pain. In a statement of August 2002, the Veteran indicated that he had sought low back treatment immediately after service from a Dr. Vick, who had since passed away. Additionally noted was that the Veteran had been unable to locate records of this treatment. In a letter of August 2002, a private physician indicated that he had been seeing the Veteran for a low back problem since March of that same year. That physician noted that the Veteran's history was significant for an injury sustained during service. Reportedly, while crossing a log, the Veteran slipped and fell on his back, injuring his hip and lower back. According to the Veteran, this occurred while the Veteran was stationed at Fort Hood approximately 32 years earlier. The physician additionally noted that the Veteran had reported pain off and on since his initial injury, leading him to seek medical care, including pain management and therapy "off and on" since that time. According to the Veteran, there had also been aggravating episodes requiring him to limit his daily function and activities. The Veteran reported that he had seen Dr. Vick in the past, and had recently been seen at the VA Medical Center in Fayetteville, North Carolina. Additionally reported was that, in January 2001, the Veteran experienced significant enough pain and irritation in his lower back that he required hospitalization at the VA Medical Center for over two weeks for pain management and care. According to the private physician, the Veteran's history was consistent with history that he had injured his back while in the military at Fort Hood. Moreover, based upon information provided by the Veteran, that physician saw no reason to question that the Veteran's history of back problems could be traced to that point in time. The physician further indicated that the Veteran's diagnoses included sacroiliitis and lumbar disc disease. Moreover, he had been given a diagnosis of spinal stenosis of the lumbar region, in addition to low back pain in July 2001. Apparently, the Veteran had provided documents supporting his back pain for the private physician's verification. Moreover, that physician had reviewed several of the Veteran's radiographic studies, as well as an MRI report, which he felt were consistent with the Veteran's evaluation and care. According to his private physician, the Veteran's medical problems supported his claim for disability, in particular, since he had had the opportunity to see the Veteran for several months, beginning with his initial visit in March 2002. In correspondence of September 2002, the Veteran's wife indicated that she had lived with the Veteran for more than 25 years, and that they had been married in 1980. According to the Veteran's spouse, she had seen him in distress and discomfort, and unable to move. Moreover, by her report, the Veteran had at times been so tender in his lower left back area that she had been unable to touch him. The Veteran's wife recalled that the Veteran had experienced problems related to his back even while they were courting, five years prior to the time that they were married. Reportedly, during those days, it was quite difficult for the Veteran to relax. Moreover, it was hard for him to lie in bed, resulting in a morning routine of trying to get him out of bed. According to the Veteran's spouse, he was either not able to sit up, or if he were able to sit, there was a problem standing or tying his own shoes. Reportedly, the Veteran's wife often had to help him get dressed and properly bathe. While she constantly attempted to get him to seek medical treatment, money and time on the job always seemed to take precedence over his need for physical relief. While on one occasion, she was able to convince the Veteran to see Dr. Vick, the medicine that Dr. Vick provided the Veteran affected his sexual desire and/or drive. Significantly, Dr. Vick had apparently informed the Veteran's wife that he could not understand how the Veteran had been able to go so long without taking something for his pain and discomfort. In separate correspondence of September 2002, a friend, K.M., indicated that he had known the Veteran for more than 35 years. Reportedly, K.M. recalled that the first time he became aware of the Veteran's back problem was during a small Christmas gathering in 1968. At that time, when the Veteran's friend asked him what was wrong, the Veteran reportedly explained that, during routine training at Fort Hood, he had fallen and damaged his back. As a result, he was taken off duty for a few weeks, and then returned to duty. According to the Veteran, he had been seeing a doctor ever since with the same complaint. Significantly, the Veteran's friend indicated that the aforementioned Christmas gathering ended with the Veteran stretched out on the floor, since lying on hard surfaces seemed to help. Later, the Veteran's friend assisted him with medical services after the pain intensified, leaving him with great difficulty when trying to move. According to the Veteran's friend, he could not remember a time since he had known the Veteran when he was totally free of limitations from his back problems. In an additional letter dated in September 2002, a minister and friend of the Veteran indicated that he had known the Veteran since grade school. Reportedly, during numerous visits, he had heard the Veteran complaining of back pain, as well as pain in his legs. According to that minister, it was not until the Veteran enlisted in the Armed Forces that he started suffering in that manner. In another letter dated in September 2002, the Veteran's wife's aunt indicated that, during numerous visits to see the Veteran, she had observed him in various stages of discomfort. Reportedly, the Veteran complained of dizziness, as well as back pain, and pain in his right and left legs. As far back as the aunt could remember, the Veteran reportedly experienced discomfort from back problems, and had been going to doctors for that condition. In another September 2002 letter, the Veteran's niece indicated that she had been present when the Veteran had to go to the hospital in 2001 for his back. According to the Veteran's niece, she had never seen someone in so much pain. Reportedly, the Veteran's niece had heard him complaining about headaches, leg pain, and numbness in his thighs, and had seen the muscles in his legs and back jerking and twitching. Moreover, as far back as she could remember, including when she was a little girl, the Veteran had experienced trouble sitting, and often preferred sleeping on the floor to sleeping in a bed. In an additional letter of September 2002, a friend of the Veteran and his wife indicated that he had known the couple since 1972. Reportedly, during that time, she had seen the kind of back pain the Veteran typically experienced. According to the Veteran's friend, she believed he had problems due to his back and the medicine he was taking, at a minimum, when the timing of the medicine was not correct. Reportedly, while she had advised the Veteran to stop working, he was the sole provider for his family. Significantly, according to the Veteran's friend, she had seen him when no one could touch him due to the fact that he was in so much pain, to the extent that the only way he could get around was with the help of another person. In an additional statement of September 2002, another individual, P. E., indicated that he had worked for Dr. Vick for several years beginning in 1975. Reportedly, Dr. Vick had requested that he bury all of the physician's patient records in a 4 x 6 foot hole in the physician's backyard. This was because, as the physician explained to him, he did not wish to have his records exposed to the public. In his March 2004 Substantive Appeal, the Veteran indicated that, in his opinion, given that he had begun to show symptoms of his current low back condition which were observed by his friend within four months of separation from service, that the condition had been observed over the years since then, and that his current condition had been linked to his military service by a competent medical professional, service connection for his low back disability should have been granted. VA medical records covering the period from April to October 2003 show continued treatment for ongoing low back problems. During the course of his March 2005 hearing, the Veteran testified that he slipped and fell while crossing a stream during service at Fort Hood, Texas, injuring both his low back and right leg. According to the Veteran, at that time, he didn't really think anything of the low back pain, which was slight in degree. However, his leg was scarred, with the result that he sought medical treatment at the hospital. According to the Veteran, he was then released, given that medical personnel had not found any sign of a crack or break. Reportedly, he was subsequently put on light duty for a period of time, which, as he recalled, was about three or four weeks. The Veteran additionally noted that, while in the field during service, he had to carry around heavy mortar equipment, as well as mortar rounds, which he believed had taken a toll on his back. Reportedly, following discharge, the Veteran first sought treatment for his low back approximately six months after separation from a private physician. According to the Veteran, when he first sought that treatment, his back pain was excruciating, extending to his hips and legs. Reportedly, the Veteran did not know whether his pain had been of sudden onset, or whether it had been getting worse since his discharge, though he did indicate that he was not having any pain when he separated from service. Further noted was that, while the Veteran's physician had not performed radiographic studies, he did treat the Veteran's condition with medication for pain and inflammation. According to the Veteran, after that first postservice treatment, it might have been another year or a year and a half before he again received treatment, due to the fact that, at that time, his pain would come and go. The Veteran testified that the treating physician had since died, and that his records had been destroyed. Accordingly, records of the treatment in question were unavailable. According to the Veteran, the first time he remembered receiving any radiographic studies of his back was in 2001. VA records covering the period from June 2002 to October 2006 show treatment primarily for prostate cancer, and other unrelated conditions. However, the Veteran was noted to have ongoing low back pain. Additional VA medical records covering the period from March to September 2007 likewise show ongoing treatment for low back pain. That treatment included physical therapy, including TENS therapy and diathermy. Additionally noted was that the Veteran had been issued a cane and a brace. At the time of a November 2007 VA examination, the diagnoses noted were degenerative disc disease of the lumbar spine and lumbar strain. The examining physician's assistant noted that he had reviewed the Veteran's claims file and medical records, and that the Veteran reported that, during the summer of 1968, he was on a field trip on a hot day. Reportedly, the Veteran jumped from a log in the water to the bank, injuring his back and right leg when he fell. Subsequently, the Veteran received treatment at a hospital. Additionally noted was that the Veteran had been seen by a Dr. Vick in Fayetteville, North Carolina, for therapy and pain pills soon after service. According to the Veteran, since he left the Army, he had been seen on multiple occasions at the Fayetteville VA Medical Center for his back. The Veteran indicated that he currently had a dull pain which was usually present, with accompanying stiffness, but no weakness. Additionally noted were radicular symptoms on the right. Following examination, the examiner offered his opinion that the Veteran's present degenerative disc disease of the lumbar spine and lumbar strain were not a consequence of his time in the Army. Significantly, the examiner noted that there was no evidence of trauma in service, and that the Veteran had not been seen for low back problems during his active military service. VA records covering the period from July 2005 to November 2009 once again show treatment primarily for other medical problems, though the Veteran continued to complain of chronic low back pain. At the time of a July 2011 VA examination, the examining physician indicated that he had reviewed the Veteran's claims file, as well as his medical records. Noted at the time was that the Veteran had reported a fall on maneuvers while stationed at Fort Hood during service. Reportedly, while crossing a stream, the Veteran had jumped from a log to reach the bank. However, he was unable to do so, and fell, landing on the rocks. The Veteran was reportedly taken to the base hospital, treated, and released, following which he was put on physical profile for a short period of time. The Veteran was subsequently released from his physical profile, and, apparently, did well, though over time, his low back became worse and continued to progressively worsen. According to the Veteran, he experienced problems with numbness, paresthesias, leg and foot weakness, and falls, as well as unsteadiness. Additionally reported was a history of fatigue, decreased motion, stiffness, weakness, spasm, and spine pain. According to the Veteran, the location and distribution of his pain was in the upper middle lumbar area. The Veteran described his discomfort as a severe constant stabbing pain, with radiation of that pain to his right leg, similar to someone sticking needles into his leg. Once again, it was noted that the Veteran utilized both a cane and a back brace. Physical examination showed significantly decreased range of lumbar spine motion in all directions. On lower extremity muscle strength testing, the examiner noted that the Veteran's strength was not consistent between the examination and the examiner's own observations. Lasegue's sign was positive on both sides, and, when testing for nonorganic physical signs, the examiner indicated that he found inconsistent ranges of motion between examination and observation. However, the examiner did note that the Veteran had significant difficulty in dressing, including putting on his pants, socks, and shoes. The pertinent diagnosis noted was degenerative disc disease of the lumbar spine. According to the examiner, he had reviewed the Veteran's service treatment records, as well as private medical records and VA records, in addition to other pertinent evidence, including letters from the Veteran's friends and family (i.e., nonmedical persons). Following a review of that evidence, as well as an examination of the Veteran, the examiner was of the opinion that it was less likely than not that the Veteran's current back degenerative disc disease had been caused by or a result of his military service. In that regard, the examiner noted that service treatment records showed an incident where the Veteran had injured his leg while in the field, and that he had undergone radiographic studies, and been placed on light duty for 48 hours. However, in a report of medical history obtained in conjunction with the Veteran's 1968 service separation examination, the Veteran specifically indicated that he did not have recurrent back pain. Under the circumstances, the examiner found no causal relationship between the Veteran's back condition and his military service. According to the examiner, the actual start date for the Veteran's low back problems was unavailable from the record, though there was a letter noting that certain of the Veteran's medical records had been buried by his private treating physician. The examiner acknowledged that an August 2002 letter from the Veteran's private physician attributed the Veteran's low back disability to military service. However, the VA examiner found no evidence in the record that this physician had access to any of the Veteran's records prior to 2001. Significantly, the VA physician indicated that he had reviewed letters from various lay people dated in September 2002, but that no causal relationship could be established between service and the Veteran's current low back disability based on information in those letters. Moreover, none of the letters in question gave a reason to dispute the Veteran's denial of recurrent back pain at the time of his separation from service. Law and Regulations Service connection may be established for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d) (2012). The fact that an injury might have occurred in service is not in and of itself enough. Rather, there must be chronic disability resulting from that injury. In order to establish service connection for a claimed disorder, there must be: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record, as well as the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a) (2012). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim, or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Some chronic disorders, to include osteoarthritis, may be presumed to have been incurred in service where they are demonstrated to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.309 (2012). Analysis In the case at hand, the Veteran has testified that he injured his back, as well as his leg, during a fall in service in May 1968. The Veteran is competent to make such a report. However, he has additionally testified that his back pain was slight at that time, and was not, in fact, present at the time of his separation from service. In that regard, the Veteran specifically reported on his July 1968 report of medical history at separation that he had not suffered from recurrent back pain. Moreover, he affirmatively testified during his March 2005 Board hearing that he did not have any back pain at the time of his separation from service. These reports are additionally supported by the report of the Veteran's physical examination at separation, which showed his spine to be within normal limits. Accordingly, both the service treatment records and the Veteran's testimony indicate that a chronic low back disability did not become manifest during military service. Further, the Veteran's credibility is at issue as to the onset of any back pathology in service. Significantly, contemporaneous records fail to reveal any complaint of back pain. While the Veteran has indicated that his primary concern was his leg, it seems less than credible that all residuals of the Veteran's fall would not have been reported at the time of that incident. It is deemed significant that at no time during treatment for the leg or thereafter during service that reference was made to back pain. Moreover, when first seen for back complaints in 2001, a one year history of back pain was initially recorded. It was only later that a longer history was recalled. The earliest evidence of any kind regarding postservice manifestations of low back problems consist of the Veteran's lay testimony, and that of his friend, K.M. In that regard, K. M. reported that the first time he became aware of the Veteran's back problem was during a Christmas gathering in 1968, which would have been approximately five months following the Veteran's separation from service (i.e., five months from early July). Significantly, the Veteran affirmatively testified at his March 2005 Board hearing that he first sought postservice treatment for low back pain approximately six months after service, and could not recall whether that pain had increased gradually, or was of sudden onset. Initially, the Board finds that K.M.'s testimony is only partially credible, and that the evidence indicates that the Veteran did not receive medical care for low back problems "ever since his fall in service." In that regard, and as noted above, the Veteran affirmatively testified that he did not have low back pain at separation from service, and that, following his discharge, he did not see a physician for low back problems for approximately six months. Accordingly, the Board finds K.M.'s report that the Veteran informed him that he had been seeing a doctor for low back problems ever since his fall in service not credible, inasmuch as that report tends to contradict the Veteran's testimony in service treatment records, both of which indicate that the Veteran was pain free at separation from service, and did not receive any follow-up care during service. Moreover, that report also tends to contradict the Veteran's testimony that he was seen on only one occasion by Dr. Vick approximately six months following service discharge, but then did not see him again for a year or a year and a half. Inasmuch as the Veteran is the one who would have received the care, the Board credits his account of postservice treatment he received over that of his friend, K.M. Moreover, the credibility of all such reports is somewhat suspect, given the early 2001 records which report, as noted, a few months to one year history of right hip and low back pain. Those records are significant, given that there was no long term history of continued back pain. Based on the Veteran's testimony and K.M.'s testimony of first witnessing the Veteran's back pain just prior to Christmas 1968, and excluding K.M.'s noncredible testimony concerning continuity of the Veteran's medical care following his fall, the evidence of record does not show continuous low back symptomatology from the date of separation from service up to the present. Rather, the evidence indicates that there was a gap in low back symptomatology of at least a number of months, and, as noted, a more significant gap as recorded in 2001 records. Significantly, other lay testimony from the Veteran's friends and family does not include any direct observation of low back pain dated farther back than approximately 1975 (i.e., the Veteran's wife's testimony indicating that she noticed that the Veteran had low back problems as early as five years prior to their 1980 marriage). Notably, the Veteran's minister did indicate that it was "not until the Veteran enlisted" that he began suffering from back pain. However, that statement does not tend to indicate that the minister either directly observed the Veteran having back problems immediately after service, or that he otherwise had any knowledge that the Veteran experienced continuous low back symptomatology from the date of his separation from service up to the present. Rather, it generally indicates that the Veteran did not have any back problems prior to service, and tends to indicate that the Veteran experienced some type of back problem in service. Accordingly, given the observations provided in lay testimony, in conjunction with the absence of any medical documentation showing low back problems immediately after service, the weight of the evidence would appear to indicate that the Veteran has not experienced ongoing low back symptomatology from the time of his separation up until the present. The Board acknowledges that at least some of the lay testimony of record suggests that the Veteran's postservice low back symptomatology began very soon after service, and, accordingly, at least suggests that the current symptomatology, alleged to have existed from at least five to six months following separation until the present, might be related to the Veteran's alleged inservice injury. However, that suggestion is unsupported by the medical evidence of record. In that regard, following the July 2011 VA examination, the examining physician specifically found that, following a thorough review of the record and examination of the Veteran, it was less likely than not that the Veteran's current low back degenerative disease was caused by or a result of military service. That physician's specific rationale was that the Veteran's medical history at separation indicated that he did not have recurrent back pain, and, accordingly, there was no basis for finding any causal relationship between the Veteran's military service, including his inservice fall, and his current back condition. The physician additionally noted that he had reviewed all the lay testimony of record, but that no causal relationship could be found based on the information in those letters. Moreover, none of the letters gave any reason to discredit the Veteran's denial of recurrent back pain at the time of his separation from active service. It is also noted that degenerative disc disease is not a presumptive disorder on the chronic disease list. See 38 C.F.R. §§ 3.307, 3.309. As can be seen from the above, the August 2002 private physician's letter would seem to support a finding that the Veteran's current low back disability is related to service, given that the physician found that the Veteran's medical problems supported his claim for disability for back problems. However, that report was based on a limited review of documents supporting the Veteran's back pain, including radiographic studies and an MRI report and a noncredible history of back injury. Moreover, there is no indication that the physician examining the Veteran in August 2002 reviewed his service treatment records, to include the Veteran's negative report of recurrent back pain on separation from service. Under the circumstances, the Board attaches significantly less weight to that physician's conclusion than to that of the July 2011 VA examiner who did specifically review the private physician's report, and was thus aware of this critical piece of evidence tending to show that the Veteran had not experienced ongoing low back symptomatology during service. Moreover, although the Veteran, his family, and friends appear to believe that his current low back disability is related to service, as lay people, they lack sufficient medical expertise to provide more than a minimally probative opinion regarding whether any nexus exists between the Veteran's current low back disability and his reported back injury during service. Rather, evidence which requires medical knowledge must be provided by someone qualified as an expert by knowledge, skill, experience, training, or education, none of which the Veteran, his family, or friends possess. See Jandreau v. Nicholson, 492 F. 3d 1371 (Fed. Cir. 2007). Under the circumstances, the weight of the overall evidence is against a finding that the Veteran's current low back disability is related to service, to include his inservice fall. Based on the aforementioned, it is clear that the Veteran experienced only slight and transitory, if any, back pain during his period of active military service. Similarly clear is that there was no evidence of any back problem at the time of the Veteran's service separation. In fact, the earliest clinically confirmed evidence of a chronic back problem dates from a point in time many years following the Veteran's separation from service. Under the circumstances, the Veteran's claim for service connection must be denied. ORDER Entitlement to service connection for a low back disability is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs