Citation Nr: 1323008 Decision Date: 07/18/13 Archive Date: 07/24/13 DOCKET NO. 07-23 565 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for residuals of a right hand fracture, to include a right wrist disorder. 2. Entitlement to service connection for a right elbow injury. 3. Entitlement to service connection for a right shoulder injury with arthritic changes. REPRESENTATION Veteran represented by: AMVETS WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from May 1966 to November 1986. This matter comes before the Board of Veteran's Appeals (Board) on appeal from a rating decision issued in March 2007 by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The Veteran provided testimony before the undersigned Veterans Law Judge sitting at the Phoenix RO in May 2012. A transcript of the hearing has been associated with the Veteran's claims file. In August 2012, the Board remanded the issues captioned above and the issues of service connection for an anxiety disorder, a lung disorder, asthma, and coccidioiodmycosis for further development. In February 2013, the agency of original jurisdiction (AOJ) granted service connection for an anxiety disorder, asthma (as the only diagnosed lung disorder), and coccidioiodmycosis. Therefore, these issues are no longer before the Board on appeal. The remaining issues return to the Board for further appellate review. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. The Virtual VA paperless claims processing system contains additional VA outpatient treatment records dated through October 2012 that were considered by the AOJ in the February 2013 supplemental statement of the case. In the August 2012 decision, the Board noted that the issues of entitlement to service connection for an aortic aneurysm, service connection for tooth number 30 for treatment purposes only, a compensable rating for hemorrhoids, and a compensable rating for a scar residual of cholecystectomy were raised by the record, but have not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction, and they are again referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Residuals of a right hand fracture, to include a right wrist disorder, are not shown to be causally or etiologically related to any disease, injury, or incident in service, and arthritis did not manifest within one year of the Veteran's discharge from service. 2. A right elbow injury is not shown to be causally or etiologically related to any disease, injury, or incident in service, and arthritis did not manifest within one year of the Veteran's discharge from service. 3. A right shoulder injury with arthritic changes is not shown to be causally or etiologically related to any disease, injury, or incident in service, and arthritis did not manifest within one year of the Veteran's discharge from service. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a right hand fracture, to include a right wrist disorder, are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 2. The criteria for service connection for residuals of a right elbow injury are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 3. The criteria for service connection for residuals of a right shoulder injury with arthritic changes are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2011). 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that 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 the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a February 2007 letter, sent prior to the initial March 2007 rating decision, advised the Veteran of the evidence and information necessary to substantiate his service connection claims as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, the February 2007 letter informed the Veteran of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Relevant to the duty to assist, the Veteran's service treatment and personnel records, as well as VA and private treatment records, have been obtained and considered. Additionally, the Veteran has not reported, and neither does the evidence of record show, that he is in receipt of Social Security Administration (SSA) disability benefits for his claimed disabilities. Absent any evidence showing that the Veteran is in receipt of said benefits for his claimed disorders, VA need not attempt to obtain his SSA records. Golz v. Shinseki, 590 F.3d 1317, 1323 (2010). The Veteran has not identified any additional, outstanding records that have not been requested or obtained. Therefore, the Board finds that VA has satisfied its duty to assist in obtaining all available records. Additionally, the Veteran was afforded a VA examinations in November 2009 and September 2012 in order to adjudicate his claims of entitlement to service connection for residuals of a right hand fracture including a right wrist disorder, residuals of a right elbow injury, and (for the September 2012 examination only) residuals of a right shoulder injury with arthritic changes. In the August 2012 remand, the Board concluded that the November 2009 had some deficiencies and ordered another examination. The VA examiner in September 2012 offered etiological opinions as to the Veteran's claimed disorders and based her conclusions on an interview with the Veteran, a review of the record, and a full examination. Moreover, she offered clear conclusions with supporting data as well as reasoned medical explanations. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet.App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). As such, the Board finds that the opinions proffered by the VA examiner in September 2012 are adequate to assist VA in deciding those claims. Additionally, in May 2012, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the May 2012 hearing, the undersigned enumerated the issues on appeal. Also, information was solicited regarding the Veteran's in-service experiences he alleges resulted in his claimed disorders, the type and onset of symptoms, and his contention that his military service caused his disorders. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, while the hearing discussion raised the possibility that his alleged disorders were related to service, the Board secured a VA examination and opinion in September 2012 in order to address the issues. Moreover, updated treatment records were also obtained. Therefore, as a result of the Board's August 2012 remand, all available evidence has been obtained and there is no possibility any additional evidence has been overlooked with regard to the Veteran's claims for service connection. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. As indicated previously, the Board remanded the case for additional development in August 2012. Specifically, the AOJ was directed to provide the Veteran with an opportunity to identify any outstanding treatment records, obtain updated VA treatment records, and afford him a VA examination with opinions in order to determine the etiology of his claimed disorders. Subsequent to the Board's remand, the AOJ provided the Veteran with a letter in August 2012 requesting that he identify any outstanding treatment records to which he did not respond. The AOJ also obtained VA treatment records dated through October 2012 and afforded the Veteran a VA examination in September 2012 that addressed the Board's inquiries. Therefore, the Board finds that the AOJ has substantially complied with the August 2012 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); 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 (2002). Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis The Veteran served as a U.S. Marine Corps supply and retail store specialist. He retired at the rank of Master Sergeant and did not perform combat service. The Veteran contends that his right hand/wrist, right elbow, and right shoulder disorders are residuals of traumatic injuries incurred in active service. 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, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in- service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Board must weigh any competent lay evidence and to make a credibility determination as to whether it supports a finding of service incurrence; or, if applicable, continuity of symptomatology; or both, sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Layno v. Brown, 6 Vet. App. 465 (1994). The credibility of lay evidence may not be refuted solely by the absence of corroborating contemporaneous medical evidence, but it is a factor. Davidson v. Shinseki, 581 F.3d at 1313, 1316 (Fed.Cir. 2009). Other credibility factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). 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. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Residuals of a Right Hand Fracture, to include a Right Wrist Disorder In an October 2006 claim, the Veteran reported that he fractured his right hand in 1973. In a November 2009 VA examination, the Veteran pointed to his right wrist and reported that a box fell on his right hand, requiring a cast for six weeks with no treatment thereafter. At his May 2012 hearing before the undersigned Veterans Law Judge, the Veteran asserted that he fractured his right hand at Marine Corps Base Camp Butler in Okinawa in approximately 1972. See transcript, p. 7. The Veteran explained that he jammed his right hand into a water basin faucet in the course of breaking up a fight. Id. at p. 7. He stated that he was treated in service for the fracture with a cast, and that he had periodically complained about the pain. Id. at p. 8. The Veteran stated that his right hand now feels weak at times, and has arthritis and pain on range of motion. Id. at pp. 7, 9. Service personnel records show that the Veteran was assigned duties at Camp Butler from May 1972 to May 1973. Service treatment records are silent for any immediate examination and treatment of an injury to the right hand or wrist at any time. In a December 1976 Report of Medical History, the Veteran noted that he had experienced broken bones in the past without further details. The examining physician noted that the Veteran sustained a fractured right hand in 1973 and found that it had healed well with good results and that there was no complication and no sequelae. In Reports of Medical Examination dated July 1971, December 1976, February 1978, April 1980, January 1984, November 1984, April 1986, and October 1986, examiners found that the Veteran's upper extremities were normal with no further notations of residuals of a 1973 injury after 1976. During active service, the Veteran successfully performed duties as a warehouseman, retail store manager, security guard, supply administrator, and recruiter. After service, the Veteran was employed in an insurance business and worked for the U.S. Postal Service for twenty years, retiring in 2006. In June 1987, a VA physician performed a general medical examination and noted no joint complaints and a normal musculoskeletal system. The Veteran submitted an image of a February 2008 X-ray of his wrist with the handwritten notation "arthritis of the distal radioulnar joint." It appears to have been obtained by the Veteran's private orthopedic physician. The Veteran was provided with a VA examination of his right hand in November 2009. The examining physician noted that he did not have access to the Veteran's claims file, and "[a]ll the information I have is based on what the patient told me today. He seemed sincere....The history of the right hand is that in 1973 a box fell onto the right hand and broke a bone and [the Veteran] points to the wrist and not the hand itself. He was casted for about six weeks and now he states that he has intermittent stiffness and points to the area of the distal radius and ulna and not to the metacarpals or fingers." On examination, the Veteran had no visible deformity of the right wrist or hand. The fingers were all normal in appearance and fully flexed easily. There was mild discomfort with direct pressure over the distal radial ulnar joint. There was normal wrist range of motion with no pain. The examiner found that X-rays of the right wrist show some degenerative changes "which could be associated posttraumatically at the distal radial ulnar joint accounting for the symptoms in the wrist and the discomfort to palpation over the distal radial ulnar joint." The examiner summarized that "[a]s far as the right hand is concerned there is no history of hand...injury or deformity or loss of motion but it is the right wrist that was injured and he has some degenerative change at the distal radial ulnar joint." In August 2012, the Board remanded the claim in part because the examiner was not aware that the record showed two conflicting reports from the Veteran of the circumstances of the injury and because the examiner's opinion that the current degenerative changes "could" be associated with an injury was inconclusive. In September 2012, the Veteran was afforded another VA examination. At such time, a VA examiner noted a review of the claims file and acknowledged awareness of the service treatment record entries of a history of a right hand fracture, the Veteran's two conflicting reports of the circumstances, and the report of the 2009 examination. On examination of the right hand and fingers, the examiner noted a reduced range of motion, pain on motion, flare-up pain overuse, and mildly reduced grip strength of the right fingers. On examination of the right wrist, she noted a reduced range of motion, pain on motion, flare-up pain on overuse, and weakness and incoordination. Concurrent X-rays showed degenerative changes but no evidence of a fracture or dislocation. The examiner did not comment on the February 2008 X-ray that showed arthritis of the distal radioulnar joint. She noted that the Veteran's symptoms in 2009 were significantly different from those currently observed and that the circumstances of the injury remained in conflict. The examiner further noted that the service treatment records showed no evidence of immediate treatment and that later examiners noted no abnormalities, residuals, or sequelae. Therefore, she concluded that the current degenerative changes of the right hand and wrist were not caused by the claimed in-service injury. VA primary care treatment records through October 2012 show general notations of osteoarthritis as an ongoing medical issue but are silent for any specific symptoms or treatment for the right hand or wrist. Some entries note that the Veteran denied any deformity, limitation of motion, or musculoskeletal pain. The Board concludes that service connection for residuals of a right hand fracture, including a right wrist disorder, is not warranted. The Veteran is competent and credible in his reporting of his current observable symptoms and loss of function as they have been confirmed in the most recent VA examination. There is also evidence of a current diagnosis of arthritis in the distal radioulnar joint and joints of the fingers. The Veteran is also competent to report the circumstances of an injury in service. Although the Board will accept the Veteran's report that he experienced some form of trauma to his hand in 1973, the Board assigns no probative weight to his report of a fracture as there is no record of immediate treatment, imaging studies to confirm a fracture, casting, or current studies that show evidence of an old fracture. Further, the Veteran's report of the circumstances is inconsistent. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza, supra. In light of the inconsistencies as evidenced by the Veteran's own reports as well as the contemporenous service treatment records, the Board finds the Veteran's report of a fracture to the right hand to be not credible. Moreover, the military examiner noted in 1976 that any fracture was completely healed without complications. Many examinations in 1976 and later that show no reported chronic symptoms or abnormalities. Therefore, the Board concludes that, even if an injury had occurred in 1973, the service treatment records fail to show chronic residuals. Rather, such indicate that the injury was completely healed. Furthermore, the Veteran worked successfully in several military and post office occupations from the 1970s to his retirement in 2006 without limitations. The first medical evidence of arthritis of the wrist was in the February 2008 X-ray and arthritis of the fingers in the September 2012 X-ray. Therefore, the Board finds that presumptive service connection for arthritis, to include on the basis of continuity of symptomatology, is not warranted. See Walker, supra. The Board places greatest probative weight on the opinion and rationale of the VA examiner in September 2012 who reviewed and discussed the entire history, including the Veteran's lay statements, and concluded that the current arthritis of the fingers and wrist was not incurred in service. As indicated previously, the VA examiner offered clear conclusions with supporting data as well as reasoned medical explanations. See Nieves- Rodriguez, supra; Stefl, supra. Therefore, the Board accords great probative weight to the September 2012 VA examiner's opinion. The Board places no probative weight on the opinion of the VA physician in 2009 because it was conditional and based on an inaccurate history provided by the Veteran. In this regard, such opinion is speculative in nature. Medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. 38 C.F.R. § 3.102; see also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (a doctor's statement framed in terms such as "could have been" is not probative); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (a generic statement about the possibility of a link is too general and inconclusive); Bostain v. West, 11 Vet. App. 124, 127-28 (1998), quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993), (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship); Morris v. West, 13 Vet. App. 94, 97 (1999) (a diagnosis that the appellant was "possibly" suffering from schizophrenia was deemed speculative). Moreover, such opinion is based on the Veteran's reported history of a fracture of his right hand, which, as previously discussed, the Board has found to be not credible. The Board notes that in Kowalski v. Nicholson, 19 Vet. App. 171 (2005), the Court, citing its earlier decisions in Swann v. Brown, 5 Vet. App. 229 (1993) and Reonal v. Brown, 5 Vet. App. 458 (1993), reaffirmed that, in evaluating medical opinion evidence, the Board may reject a medical opinion that is based on facts provided by the Veteran that have been found to be inaccurate or because other facts present in the record contradict the facts provided by the Veteran that formed the basis for the opinion. Id. at 179. In Kowalski, the Court declared, however, that the Board may not disregard a medical opinion solely on the rationale that the medical opinion was based on a history provided by the Veteran, and instead must evaluate the credibility and weight of the history upon which the opinion is predicated. Id. In Coburn v. Nicholson, 19 Vet. App. 427 (2006), the Court, citing Kowalski, as well as Swann and Reonal, emphasized that the Board may not disregard a medical opinion solely on the rationale that the medical opinion is based on a history provided by the Veteran. Id. at 432-33. Furthermore, the physician did not acknowledge the contents of the service treatment records that showed a completely healed wrist in 1976 and no further abnormalities. Therefore, such opinion was based on an incomplete and inaccurate factual premise. Consequently, for the foregoing reasons, the Board accords no probative weight to the 2009 VA physician. The Board has considered the Veteran's assertions that his residuals of a right hand fracture, to include a right wrist disorder, are related to service. As indicated previously, he is competent to report current observable symptoms and an injury in service; however, as a lay person, he is not competent to offer an opinion regarding the etiology of his right hand/wrist disorder, diagnosed as degenerative changes. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, such an opinion would necessarily consider the etiology of degenerative changes or arthritis, which requires specialized testing such as an X-ray to diagnose. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board finds that residuals of a right hand fracture, to include a right wrist disorder, are not shown to be causally or etiologically related to any disease, injury, or incident in service, and arthritis did not manifest within one year of the Veteran's discharge from service. As the preponderance of the evidence is against this claim, the "benefit of the doubt" rule is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Right Elbow Injury The Veteran contended in his October 2006 claim that his "1984 exam shows complaints of pain with right forearm but the records show I was seen in the emergency room with fracture of the LEFT radial head. The X-ray report was in error as it was the RIGHT elbow and this still gives me problems with painful motion." (Emphasis in original.) At his May 2012 hearing before the undersigned Veterans Law Judge, the Veteran asserted that at Camp Kinser, Okinawa, in 1979 or 1980, as he was walking down the stairs from his quarters to the parking lot, he "somehow went from the top of the stairs to the bottom all at once." See transcript, p. 23. The Veteran stated that he broke his fall with his elbow. Id. at p. 23. He testified that he then went to sick bay, and then to the Naval Hospital, where x-rays were taken and he was put in a sling for about 3 weeks. Id. at p. 23. The Veteran stated that he was diagnosed in service with a "real bad strain," and told that "it's gonna cause serious problems...on through your career." Id. at p. 23. He noted that he did not break anything. Id. at p. 23. The Veteran stated that throughout his career, anytime he did any real exertion, exercise, or constant repetition of movement, his right elbow got stiff and sore. Id. at p. 23. He noted that he continues to have stiffness, pain, and limited motion. Id. at p. 24. He also reported that his physician has diagnosed arthritic changes. Id. at pp. 24-25. The Veteran's service treatment records include no complaints, diagnosis, or treatment of a right elbow disorder. In February 1981, the Veteran sought treatment in a military emergency room after falling down a step and landing on his left elbow; the a military physician found limited range of motion (ROM) but no fracture, and diagnosed the Veteran with a contusion. The next day, an X-ray showed a fracture of the radial neck of the left elbow. Another physician noted no articular involvement, provided a splint, and advised a return to gentle motion in a few days. In Reports of Medical Examination dated in January 1984, November 1984, April 1986, and October 1986, clinicians found that the Veteran's upper extremities were normal. Concurrent with the November 1984 examination, the Veteran reported that he had a "problem with his right forearm." However, treatment records showed that the Veteran had at least two excisions of a right forearm cyst with a residual scar. In November 1984, the Veteran denied ever having swollen or painful joints; a bone, joint, or other deformity; or a painful or "trick" elbow. The Veteran did report a problem with his right forearm-not elbow-in his November 1984 Report of Medical History. Treatment records showed that the Veteran had at least two excisions of a forearm cyst with a residual scar. The examiner commented on eight different medical history issues but made no reference to the right forearm or to either elbow. Retirement examinations in April and October 1986 were silent for any abnormalities of the right elbow. In June 1987, a VA physician performed a general medical examination and noted no joint complaints and a normal musculoskeletal system. A February 2006 X-ray image of an unspecified elbow obtained by a private orthopedic physician contains a handwritten diagnosis of "post traumatic arthritis." In November 2009, the private orthopedic physician opined that the Veteran has right elbow arthritis which is most likely caused by or a result of a fall down stairs in 1983. The physician noted that he had not reviewed all current medical records, including the Veteran's service treatment records, but noted that he had reviewed "my own medical records, x-rays + MRI scans." The physician noted that he treated the Veteran for posttraumatic right elbow arthritis, and that the Veteran "gave a history of injury to his elbow in the Marines in 1983. X-rays suggest old radial head fracture which is consistent with his history." Notably, the 2006 X-ray obtained by this physician was not annotated as showing an old fracture. Later in November 2009, VA provided the Veteran with a VA examination of his right elbow. The examiner noted that he did not have access to the Veteran's claims file, and "[a]ll the information I have is based on what the patient told me today. He seemed sincere....[He] states that in December 1981 he fell and hurt the right elbow and states that he was in a sling for about six weeks." The Veteran reported that he experiences transient stiffness and discomfort over the outer aspect of his elbow if he puts heavy stress on his right arm. The examiner found no visible deformity, swelling, or palpable pain; however, the Veteran lacked 15 degrees of full right elbow extension. The examiner also found that X-rays showed no evidence of any old trauma, fracture, or deformity. The examiner opined that "the elbow examination to my review is completely normal but he does lack some full right elbow extension. So the diagnosis in the right elbow is mild loss of full elbow extension posttraumatic in nature secondary to alleged old radial neck fracture." In August 2012, the Board remanded the claim in part because the Veteran alleged that notations in his service treatment record pertaining to his left elbow and right forearm should apply to his right elbow. The 2009 VA physician did not review the claims file which is significant because the private orthopedic physician found that his X-rays suggested an old radial head fracture consistent with the Veteran's history, although the 2006 image submitted by the Veteran was annotated only with a diagnosis of arthritis and not a healed radial head fracture. A review of the claims file was also required because the 2009 VA examiner similarly relied on the Veteran's report of an old radial neck fracture and not the service treatment records. A new examination was also required because the two physicians reached apparently opposite conclusions when interpreting the Veteran's right elbow x-rays. In September 2012, a VA examiner noted a review of the claims file. On examination, she noted a reduced range of motion, pain on motion, and weakness of the right elbow joint. The examiner incorrectly referred to X-rays obtained in November 2009 as having shown an old healed right radial head deformity. This is contrary to the evaluation of the 2009 VA physician who found no evidence of an old fracture on X-rays taken of the right elbow in November 2009. The examiner concluded that the claimed condition, a right elbow injury, was not incurred in service because service treatment records showed no examination or treatment of the right elbow. VA primary care treatment records through October 2012 show general notations of osteoarthritis as an on-going medical issue but are silent for any specific symptoms or treatment for the right elbow. Some entries note that the Veteran denied any deformity, limitation of motion, or musculoskeletal pain. The Board concludes that service connection for residuals of a right elbow injury is not warranted. The Veteran is competent to report his current symptoms and the circumstances of an injury in-service. His reports of current limitation of motion, pain, and weakness are credible as they have been accepted and noted by both private and VA examiners. However, the Board assigns no probative weight to his contention that the 1981 records of injury and care of his left elbow are administratively in error and should refer to the right elbow. Although the records are consistent with his reports of a fall, there are two records prepared on two different days and signed by two physicians documenting a contusion and a fracture of the radial head on the left side. Additionally, in 1984, the Veteran reported a problem with his right forearm, not elbow, which was consistent with several excisions of sebaceous cysts. Therefore, as the Veteran's reports of a right elbow injury are inconsistent with the contemporaneous medical evidence of record, as documented in his service treatment records, the Board finds them to be not credible. See Caluza, supra. More importantly, after 1981, there were no other symptoms or functional problems noted by the Veteran or by physical examiners. The Veteran continued his military duties and two decades of work at the Postal Service. The medical evidence is also inconsistent regarding a current diagnosis and the presence of imaging evidence of an old radial fracture of the right elbow. The 2006 private orthopedic physician's X-ray is not annotated as to whether it is an image of the left or right elbow and is annotated only with a diagnosis of arthritis but no indication of an old radioulnar fracture. Nevertheless, in 2009, the physician again refers to X-rays that show an old radial head fracture. This is consistent with the Veteran's lay statements but not with the service treatment records. The 2009 VA examiner noted no elbow abnormalities on an X-ray but concluded that the observed limitation of motion was caused by an "alleged" old fracture. Finally, the 2012 examiner concluded that the current symptoms are not residuals of a right elbow injury because service treatment records do not mention the right elbow. However, to the extent that arthritis was diagnosed on X-ray in 2006, the Board has considered whether presumptive service connection is warranted. However, as such did not manifest until more than a year after the Veteran's separation from service in 1986, the Board finds that presumptive service connection for arthritis, to include on the basis of continuity of symptomatology, is not warranted. See Walker, supra. As indicated previously, the September 2012 VA examiner offered clear conclusions with supporting data as well as reasoned medical explanations. See Nieves- Rodriguez, supra; Stefl, supra. Therefore, the Board accords great probative weight to the September 2012 VA examiner's opinion. The Board also places great probative weight on the evidence contained in the service records. Both 1981 treatment records signed by two physicians on two separate dates address an injury and fracture of the left elbow. In 1984, the Veteran reported problems in 1984 with the right forearm, not the elbow, consistent with the cyst excisions. The examiners in 1984 and in 1986 made no observations of any residual symptoms. The Board places greater probative weight on the opinion of the 2012 VA examiner, the only post-service examiner to have reviewed the service treatment records, who concluded that there was no right elbow injury with chronic residuals in service. The Board places less probative weight on the private orthopedic physician and 2009 VA physician opinions as they were both based on the oral reports by the Veteran, which, as indicated previously, are not credible. See Kowalski, supra; Coburn, supra. Additionally, although the private physician referred to his X-rays that showed an old radial head fracture, his 2006 X-ray was not so annotated and the 2009 VA physician noted that his X-rays did not show evidence of an old fracture. The Board has considered the Veteran's assertions that his right elbow disorder is related to service. As indicated previously, he is competent to report current observable symptoms and an injury in service; however, as a lay person, he is not competent to offer an opinion regarding the etiology of his right elbow disorder. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board finds that a right elbow injury is not shown to be causally or etiologically related to any disease, injury, or incident in service, and arthritis did not manifest within one year of the Veteran's discharge from service. As the preponderance of the evidence is against this claim, the "benefit of the doubt" rule is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Right Shoulder Injury with Arthritic Changes The Veteran contended in his October 2006 claim that he "fell very hard on my right shoulder in service but did not seek treatment for it. However, I believe I did subsequently complain of pain in the right shoulder area and now I believe I have arthritic changes related to that injury." At his May 2012 hearing before the undersigned Veterans Law Judge, the Veteran asserted that his right shoulder injury arose out of the same incident in 1979 or 1980 at Camp Kinser, Okinawa, in which he allegedly hit the ground with his right elbow. See transcript, p. 27. The Veteran stated that the fall "probably hurt my shoulder, which after years, it's started to hurt....I've been having problems with it ever since." Id. at p. 28. The Veteran stated that he had treatment for his right shoulder pain in service. Id. at pp. 28-29. The Veteran's service treatment records include no complaints, diagnosis, or treatment of a right shoulder disorder. As noted above, in February 1981, the Veteran sought treatment after falling down a step and landing on his left elbow-not right shoulder. In Reports of Medical Examination dated July 1971, December 1976, February 1978, April 1980, January 1984, November 1984, April 1986, and October 1986, clinicians found that the Veteran's upper extremities were normal. In Reports of Medical History dated December 1976, February 1978, April 1980, and November 1984, the Veteran denied ever having swollen or painful joints; a bone, joint, or other deformity; or a painful or "trick" shoulder. The Veteran did report a problem with his right forearm-not shoulder-in his November 1984 Report of Medical History. No diagnosis or treatment of a right shoulder disorder after service is of record. In particular, the Veteran's private orthopedic physician and the VA primary care clinicians made no record entry regarding any ongoing right shoulder symptoms. As previously noted, the Veteran successfully completed twenty years of service in the Marine Corps and twenty years at the U.S. Postal Service. In August 2012, the Board remanded the claim in part because the Veteran was competent to report that he has experienced right shoulder pain during and after service and because the February 1981 service treatment record constituted evidence of a fall in service. The Board requested an examiner's opinion whether the Veteran's claimed right shoulder pain is etiologically related to the 1981 fall. In September 2012, a VA examiner noted a review of the claims file and incorrectly indicated that the Veteran had been diagnosed with degenerative joint disease of the right shoulder or arm in 1981. She may be referring to the Veteran's contentions as in the same report she clearly noted that there was no evidence in the file during or after service prior to her examination of an injury or treatment of the right shoulder. On examination, the examiner noted limitation of motion, pain on motion, and positive impingement tests of the right rotator cuff. X-rays were noted to show arthritis. She concluded that the current symptoms were not caused by any event in service because the service treatment records were silent for any report by the Veteran or treatment of right shoulder symptoms. VA primary care treatment records through October 2012 show general notations of osteoarthritis as an on-going medical issue but are silent for any specific symptoms or treatment for the right shoulder. Some entries note that the Veteran denied any deformity, limitation of motion, or musculoskeletal pain. The Board concludes that service connection for a right shoulder injury with arthritic changes is not warranted. The Veteran is competent and credible to report his current observed symptoms as they have been confirmed by the most recent VA examination. However, the Board concludes that the Veteran's report of a right shoulder injury in 1981 and a continuity of symptoms thereafter are not credible. As discussed above, service record entries on two separate days confirm that the Veteran injured his left elbow in a fall, not concurrent with a right elbow injury as contended by the Veteran at his hearing. No shoulder symptoms were reported by the Veteran or noted by military examiners on several occasions after 1981. The Veteran successfully performed duties as a Marine and as a Postal Service employee for several decades. Notably, no symptoms or imaging studies were noted or ordered by his private orthopedic physician from 2006 to 2009. Further, the Veteran did not report right shoulder symptoms to the VA examiner in 2009 when under examination for the right elbow symptoms, allegedly arising from the same accident in service in 1981. The Board does not reject the lay evidence solely because of the absence of treatment but also because the Veteran was examined on many occasions during and after service with opportunities to describe his symptoms, particularly when examined expressly for residuals of a fall, and did not do so. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). As arthritis was diagnosed on X-ray in 2012, the Board has considered whether presumptive service connection is warranted. However, as such did not manifest until more than a year after the Veteran's separation from service in 1986, the Board finds that presumptive service connection for arthritis, to include on the basis of continuity of symptomatology, is not warranted. See Walker, supra. The Board places greatest probative weight on the opinion of the VA examiner in 2012 that reviewed the entire record and concluded that the current right shoulder symptoms were not caused by any event in service. The opinion is consistent with the record and is the only opinion of record. Moreover, as indicated previously, the September 2012 VA examiner offered clear conclusions with supporting data as well as reasoned medical explanations. See Nieves- Rodriguez, supra; Stefl, supra. Therefore, the Board accords great probative weight to the September 2012 VA examiner's opinion. The Board has considered the Veteran's assertions that right shoulder disorder is related to service. As indicated previously, he is competent to report current observable symptoms and an injury in service; however, as a lay person, he is not competent to offer an opinion regarding the etiology of his right shoulder disorder. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The weight of the credible evidence demonstrates that the Veteran's current symptoms limitation of motion and impingement of his right shoulder elbow first manifested many years after service and are not caused by any aspect of service. As the preponderance of the evidence is against this claim, the "benefit of the doubt" rule is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for residuals of a right hand fracture, to include a right wrist disorder, is denied. Service connection for a right elbow injury is denied. Service connection for a right shoulder injury with arthritic changes is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs