Citation Nr: 1323447 Decision Date: 07/23/13 Archive Date: 08/01/13 DOCKET NO. 00-10 792 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for a chronic disability manifested by pain and numbness in the arms and hands, including as secondary to a service-connected low back disability. 2. Entitlement to service connection for a chronic disability manifested by joint pain in the shoulders, neck, legs, feet, and ankles, including as secondary to a service-connected low back disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from May 1985 to December 1985, with additional service in the Army National Guard, from which she was discharged in October 1993. These matters are before the Board of Veterans' Appeals (Board) on appeal from October 1999 and July 2001 rating decisions of the Philadelphia, Pennsylvania RO. The October 1999 rating decision, in pertinent part, denied service connection for a right shoulder condition. The July 2001 rating decision denied service connection for pain and numbness in the arms and hands, neck and left shoulder pain, leg pains, foot pains, and ankle pains. In October 2003, a videoconference hearing was held before a Veterans Law Judge who is no longer with the Board; a transcript of the hearing is included in the claims file. In April 2004, December 2008, and January 2011, the Board remanded the matters on appeal for additional development. In December 2010 and January 2011, the Veteran submitted additional evidence including VA treatment records and statements from herself and her husband; in the January 2011 remand, the Board found the Veteran's December 2010 statement describing body aches and symptoms in her hands and feet to be pertinent to the claims on appeal and noted that the Veteran had not waived RO consideration of the evidence. In June 2012, a videoconference Board hearing was held before the undersigned (to whom the case has been reassigned); a transcript of the hearing is included in the claims file. At the hearing, the Veteran submitted additional evidence with a waiver of RO jurisdiction. She also requested, and was granted, a 30 day abeyance period for submission of additional evidence; such evidence was received, also with a waiver of RO consideration. In July 2012, the Board remanded the matter for additional development. FINDINGS OF FACT 1. A chronic disability manifested by pain and numbness in the arms and hands was not manifested in service, arthritis of the arms and/or hands was not manifested in the first year following the Veteran's discharge from active duty, and the preponderance of the evidence is against a finding that the Veteran's current disability manifested by pain and numbness in the arms and hands is related to her service or was caused or aggravated by her service-connected back disability. 2. A chronic disability manifested by joint pain in the shoulders, neck, legs, feet, and ankles was not manifested in service; arthritis of the shoulders, neck, legs, feet, and/or ankles was not manifested in the first year following the Veteran's discharge from active duty, and the preponderance of the evidence is against a finding that the Veteran's current disability manifested by joint pain in the shoulders, neck, legs, feet, and ankles is related to her service or was caused or aggravated by her service-connected back disability. 3. Competent medical evidence (VA examiners' opinions) shows that the Veteran has radiculopathy of both lower extremities as neurological manifestations of her service connected low back disability. CONCLUSIONS OF LAW 1. Service connection for a chronic disability manifested by pain and numbness in the arms and hands, to include as secondary to a back disability, is not warranted. 38 U.S.C.A. 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. Service connection for a chronic disability manifested by joint pain in the shoulders, neck, legs, feet, and ankles, to include as secondary to a back disability, is not warranted. 38 U.S.C.A. 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 3. Service connection for radiculopathy of both lower extremities, as a neurological manifestation of her service-connected low back disability is warranted. 38 C.F.R. § 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of her claims. While she did not receive complete notice prior to the initial rating decision, a February 2011 letter provided essential notice prior to the readjudication of her claims. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). This letter explained the evidence necessary to substantiate her claims, the evidence VA was responsible for providing, and the evidence she was responsible for providing. It also informed her of disability rating and effective date criteria. An April 2013 supplemental statement of the case (SSOC) readjudicated the matters after the appellant and her representative responded and further development was completed. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA timing defect may be cured by the issuance of fully compliant notification followed by readjudication of the claim). At the June 2012 videoconference hearing before the undersigned, the Veteran was advised of what she still needs to substantiate the claims; her testimony reflects that she is aware of what she still needs to substantiate her claims. The Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. The RO arranged for VA examinations in July 2009 (with April 2010 addendum opinion), April 2011 (with June 2011 addendum opinion), and October 2012, and a records review and medical opinion in April 2013. As will be discussed in greater detail below, the Board finds these examinations and opinions (cumulatively) to be adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). In order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) evidence of incurrence or aggravation of a disease or injury in service; and (3) evidence of a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Disorders diagnosed after discharge may still be service connected if all the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Certain chronic disabilities (to include arthritis) may be service connected on a presumptive basis if manifested to a compensable degree within a specified period of time following discharge from active duty (one year for arthritis). 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Id. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (as in effect before and after October 10, 2006). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310 (b). The Board notes that it has reviewed all of the evidence in the Veteran's claims file and in Virtual VA (VA's online claims database), with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail every piece of evidence. See Gonzales v. West, 218 F, 3d, 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the evidence as appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claims. The Veteran's theory of entitlement to the benefit sought in this appeal is primarily one of secondary service connection. She contends that chronic disabilities manifested by pain and numbness in the arms and hands and by joint pain in the shoulders, neck, legs, feet, and ankles developed secondary to her service-connected residuals of a back injury (henceforth "back disability"). In pertinent part, service connection has been established for major depression, rated 100 percent; residuals of a back injury, rated 40 percent; disfiguring scar of the right lower eyelid, rated 10 percent; painful scar of the right lower eyelid, rated 10 percent; posttraumatic headaches with vascular and muscular contraction features associated with posttraumatic neuralgia of the 7th cranial nerve, rated 10 percent; posttraumatic neuralgia of the 7th cranial nerve associated with painful scar of the right lower eyelid, rated 10 percent; and incomplete lid closure with dry eye, tearing, and discomfort, rated 0 percent. As the Veteran has also advanced a contention that her claimed chronic disabilities may have begun during service and persisted, the Board will also address a direct (i.e., to service) causation theory of entitlement to service connection. The Veteran's STRs reflect complaints of shin and ankle pain in May 1985 and a finding of swollen ankles in June 1985. Postservice VA and private treatment records include complaints regarding, and treatment for, pain in the joints as well as diagnoses of, and treatment for, fibromyalgia, bilateral carpal tunnel syndrome, and mild de Quervain's tendonitis. A June 1989 private treatment record reflects that the Veteran sustained a right wrist injury at work in November 1988 and continued to have symptoms; the impression was ulnar wrist pain with possible signs of ulnar nerve compression, rule-out triangular fibrocartilage complex tear, rule-out ulnar column instability. Following an August 1989 diagnostic arthroscopy and open triangular fibrocartilage debridement of the right wrist, the post-operative diagnosis was triangular fibrocartilage tear, right wrist. In an April 2000 private medical opinion, the treating physician related the Veteran's right shoulder rotator cuff tendonitis and impingement to her military reserve training, firing an M-16 and a machine gun. On June 2000 VA treatment, the Veteran reported she had broken her left wrist a few weeks earlier when she fell at a grocery store. On September 2002 VA treatment, she complained of diffuse total body joint and muscle pain, including the neck, back, both arms, and both legs, ongoing for many years; the assessment was fibromyalgia with diffuse muscle and joint pain. On January 2003 private treatment, the Veteran complained of pain in the right shoulder and the right hip down to the foot since being in a motor vehicle accident two years earlier; the impression was radicular pain of the right leg and right shoulder rotator cuff tendonitis. Pursuant to the Board's December 2008 remand, the Veteran was afforded a VA joints examination in July 2009 which noted her complaints of bilateral foot, ankle, knee, and cervical spine conditions, in addition to numbness radiating to both arms, as a result of prolonged physical military activity. Following a physical examination, the diagnoses included bilateral pes planus, bilateral plantar fasciitis, and bilateral foot strain; bilateral ankle sprain; bilateral knee strain; and cervical strain. Regarding the cervical spine, bilateral feet, bilateral ankle, and bilateral knee disabilities diagnosed, the examiner opined that they are chronic in nature. Regarding the reported numbness of the hands and arms, the examiner noted that a neurologic examination of both upper extremities was normal, therefore the requested medical opinion did not apply. In an April 2010 addendum opinion, the July 2009 VA examiner opined that the Veteran's bilateral foot disability, bilateral ankle disability, bilateral knee disability, and cervical spine disability were not caused by or a result of the Veteran's military service. In a January 2011 remand, the Board found that the July 2009 VA examiner did not address the Veteran's claimed shoulder disability, did not provide a summary of the pertinent treatment records, and did not address any relationship between the claimed disabilities and the service-connected low back disability. The Board remanded the matters on appeal to afford the Veteran a new VA examination, including a summary of the pertinent treatment records, reconciling any opinion provided with the April 2000 private medical opinion; and considering and addressing the reports of a November 1988 right wrist injury, a mid-2000 left wrist fracture, and a 2001 motor vehicle accident. On April 2011 VA examination, the Veteran reported chronic pain and numbness of the feet, of the hands, of the shoulders and ankles, of all extremities, and of the cervical spine. Following physical examinations and X-rays, the diagnoses included osteoarthritis with calcaneal spur, bilateral feet; bilateral shoulder and ankle strain; severe bilateral carpal tunnel syndrome; and cervical spine strain without radiculopathy. No evidence of mononeuropathy, peripheral neuropathy, or radiculopathy was seen; the examiner opined that there is no evidence of cervical radiculopathy or lumbar radiculopathy. In a June 2011 addendum opinion, the April 2011 VA examiner noted that the origin of all disabilities claimed had been rendered established diagnoses, none of which can be related to service, noting that the service dates pre-date the established diagnoses for the foot, hand, joint, and neck pain. The examiner noted that the Veteran has extensive documentation of diffuse body pain and numbness with an established diagnosis of fibromyalgia and a suggested diagnosis of rheumatoid arthritis, with negative rheumatologic tests in the past. The examiner cited the Veteran's service treatment records and documentation of service-related chronic low back pain, a deviated nasal septum, and twisted left ankle. The examiner stated that the specific complaints on this examination are clearly documented as unrelated to service, a result of injury (1988 to the right wrist), fracture (2000 to the left wrist), and a motor vehicle accident (2001 to the low back). For rationale, the examiner stated that the cause of rheumatoid arthritis is unknown, but autoimmunity plays a pivotal role in both its chronicity and progression, and it is considered a systemic autoimmune disease. The examiner noted that more evidence is needed to verify the diagnosis of rheumatoid arthritis for the Veteran. The examiner stated that fibromyalgia syndrome, also referred to as fibrositis, is a disorder of unknown etiology. Finally, the examiner stated that a contributing factor to carpal tunnel syndrome is wrist injury and noted the Veteran's past bilateral wrist fractures. The Veteran then submitted a May 2011 opinion from private physician Dr. J.W., who stated that he has been treating the Veteran since April 1996 for pain in her back, neck, and shoulder. He stated that her conditions are the result of her work with the Army National Guard and the symptoms began in 1987. He noted that she has had right shoulder surgery and undergone extensive physical therapy. He cited her diagnoses as bulging lumbar discs with clinical radiculopathy, neck and back pain, and rotator cuff tendonitis (recurrent) of the right shoulder. Dr. J.W. opined that these disabilities are service connected in that they began during the Veteran's active duty time with the Army National Guard while she was moving equipment. Dr. J.W. opined that the Veteran's current symptoms are "the result of her service related conditions". [It is noteworthy that only Federalized National Guard service is qualifying for VA benefits.] At the June 2012 videoconference hearing, the Veteran's representative clarified that the Veteran's contentions regarding the disabilities on appeal are the same for both claims, albeit for different anatomical areas. At the hearing, the undersigned clarified for the Veteran that whether the disability causing her symptoms is bilateral carpal tunnel syndrome, fibromyalgia, or rheumatoid arthritis, all of which have been diagnosed, each began after her qualifying [for VA benefits] service and was determined to be unrelated to service (an April 2011 VA examiner). The undersigned noted upon review of the record that there is no medical opinion of record as to whether the disabilities might be secondary to the service-connected back disability. In July 2012, the Board remanded the matters on appeal to afford the Veteran a new VA examination and medical opinion to address her secondary service connection theory of entitlement. On October 2012 VA examination (pursuant to the Board's July 2012 remand), the examiner noted that the Veteran injured both ankles between 1982 and 1984 while serving in the National Guard, and both ankles have hurt since that time. The Veteran noted the diagnosis for both ankles was a bilateral ankle strain, and she later injured her back lifting ammunition in 1987; the ankle injuries predated the back injury. The Veteran stated she was unaware of any physician stating that her ankle problems were secondary to her back disability, and she noted no change in her ankle discomfort baseline since the back injury in 1987. She stated that her rationale for the ankle problems being caused by her back disability was that her representative had instructed her to claim this, but she had no specific correlation of the ankle problems being related to her back. Following a physical examination, the diagnoses regarding the ankles were mild soft tissue swelling over the lateral malleolar area and calcaneal spurs bilaterally. Regarding the Veteran's feet, the Veteran reported that her feet were wrapped tightly when she was on crutches in 1982 due to ankle sprains. She stated that physicians had attributed her foot problems to her ankle injuries. She reported no change of her foot condition since 1987 when she injured her back; the examiner noted that the foot problems predated her 1987 back injury and were unchanged since that time. The examiner noted that, per the Veteran, her foot problems were not permanently aggravated after the 1987 back injury. The Veteran reported that all of her pains were attributed to fibromyalgia, and she also had a recent diagnosis of osteoarthritis with calcaneal spurs of both feet. The examiner noted that April 2011 X-rays showed degenerative or traumatic arthritis of both feet. Regarding the Veteran's hands and fingers, the examiner noted diagnoses including bilateral carpal tunnel syndrome and osteoarthritis of the left hand. The Veteran reported that her hands began to bother her in 1982; she reported that she had injured her right shoulder and both hands while firing a machine gun. She reported tingling and weakness in both hands which had been the same since 1982 to 1984 as it was currently; she noted no changes clinically since that time. She reported that she injured the right wrist in 1988, broke the left wrist in 2000, and was in a motor vehicle accident in 2001, but these events had no effect on the bilateral carpal tunnel syndrome. The examiner noted again that her back injury occurred in 1987, and the hand problems predated the back injury and, per the Veteran, had not changed; the examiner opined that the hand problems were not permanently aggravated by the 1987 back injury. Regarding the Veteran's neck/cervical spine, the examiner noted the diagnoses included degeneration of the cervical intervertebral discs, osteoarthritis, and spondylosis. The Veteran reported having neck pains when she allegedly injured her right shoulder firing a machine gun in 1982; she reported that she was never seen for pain at that time. She reported neck pain that was localized without radicular components, although she had pain and numbness in her hands due to carpal tunnel syndrome. She reported that her neck pain was unchanged from 1982 to 2012, although a motor vehicle accident the previous year had worsened the pain. The Veteran estimated that the neck pain was "50 percent aggravating" before the car accident and "70 percent aggravating" afterward, with more pain. She noted no difference in her neck symptoms after the 1987 back injury until the motor vehicle accident; the examiner opined that the neck symptoms were not likely permanently aggravated by the 1987 back injury but were aggravated by the recent car accident. The examiner noted that a December 2009 MRI of the cervical spine showed moderate cervical spondylosis and an April 2011 X-ray of the cervical spine showed grade 1 anterolisthesis of C5 on C6 and C6 on C7. The examiner noted the Veteran's 2003 diagnosis of fibromyalgia. The Veteran reported that her fibromyalgia bothered her in her hands, and she had had diffuse muscle aches since 2000, although fibromyalgia was not formally diagnosed until 2003. She reported no changes since 2003. She reported symptoms including widespread muscle pain, stiffness, and numerous trigger points for pain in her neck, throughout her back, and at her knees. She reported the symptoms were constant or nearly so. The October 2012 VA examiner noted peripheral nerve diagnoses including lumbar radiculopathy (at L4, L5, and S1, based on subjective complaints) and carpal tunnel syndrome. The Veteran stated that the radiculopathy is her "leg claim" and contended that it began in 1987 when she was loading ammunition. She reported pain radiating down both legs associated with weakness and numbness. On physical examination, the sciatic nerve, common peroneal nerve, superficial peroneal nerve, deep peroneal nerve, tibial nerve, posterior tibial nerve, femoral nerve, internal saphenous nerve, obturator nerve, external cutaneous nerve of the thigh, and ilio-inguinal nerve were all normal bilaterally. The examiner noted June 2011 EMG testing which showed the Veteran was suffering from severe bilateral carpal tunnel syndrome, yet there was no evidence of mononeuropathy, peripheral neuropathy, or radiculopathy; the neurologist had emphasized that there was no evidence of cervical or lumbar radiculopathy. Regarding the Veteran's shoulder and arm, the examiner noted diagnoses of right rotator cuff tendinitis in 1998, right shoulder surgery (acromioplasty) in 1998, and osteoarthritis in the right shoulder in 2012. The Veteran again reported that her hands and right shoulder began to bother her in 1982; she noted tingling and weakness in both hands that had been the same since 1982 to 1984, with no changes since that time. The examiner again opined that the hand problems predated the 1987 back injury and were not permanently aggravated by the back. The Veteran stated that her "arms" claim involves the right shoulder condition, stating that the shoulder pain radiates slightly distally into the right bicep. She denied any history of radiculopathy from the neck. She reported that the right shoulder had worsened over the years, especially for a few years after undergoing rotator cuff surgery in 1988. She believed that the shoulder was "50 percent aggravating" before the motor vehicle accident earlier that year and "75 percent aggravating" after the accident. X-rays of the right shoulder indicated minimal degenerative changes. Regarding the Veteran's wrists, the examiner noted a diagnosis of bilateral tendonitis. The Veteran was unsure as to when the de Quervain's tendinitis was diagnosed, although she stated that her hands and wrists had bothered her since 1982. She stated that her "arms claims" are for the bilateral tendonitis and carpal tunnel syndrome. The examiner opined that, because the hand problems predated the 1987 back injury and per the Veteran had remained unchanged since their onset in 1982, they were not permanently aggravated by the back disability. The examiner noted that March 2010 X-rays of the right wrist showed mild cystic changes in the lunate and triquetrum bones which may be due to previous injury or early degenerative changes. A new X-ray of the left wrist was normal. Regarding the Veteran's carpal tunnel syndrome, de Quervain's tendonitis, right shoulder condition, neck condition, bilateral ankle conditions, bilateral foot conditions, and bilateral lower extremity radiculopathies, the October 2012 examiner opined that they are at least as likely as not (50/50 probability) caused by or a result of the Veteran's service. The examiner cited the Veteran's lay history that her bilateral hand conditions, bilateral wrist conditions, right shoulder condition and neck condition had begun in 1982 while she was in service firing an M16 machine gun. The examiner cited the January 1998 and April 2000 opinion statements relating the right shoulder to service and the May 2011 opinion supporting the Veteran's claims of the neck, right shoulder, and radiculopathy. The examiner also cited a statement from the Veteran's sister noting her complaints that her shoulder, hands, leg, foot, ankle, and back pains began on active duty. The examiner noted the Veteran's in-service 1985 complaints of pain in her shin, ankles, and feet. The examiner noted that the Veteran is service connected for her low back disability and has known degenerative disc disease of the lumbar spine, which is a known cause of bilateral lower extremity radiculopathies, and opined that the bilateral lower extremity radiculopathy is secondary to the back disability. The examiner further opined that the Veteran's carpal tunnel syndrome, de Quervain's tendonitis, right shoulder condition, neck condition, bilateral ankle conditions, and bilateral foot conditions are less likely as not (less than 50/50 probability) caused by or a result of the Veteran's service-connected low back disability. The examiner explained per the Veteran's lay history of her complaints that they are not back-related and predated the back injury, and they had been chronically aggravating without any changes after the back injury. The examiner opined that the Veteran's bilateral lower extremity radiculopathy is most likely caused by or a result of the service-connected low back disability, noting that the Veteran has known lumbar disc disease and has had the radicular symptoms with the onset of the back pain in 1987. The examiner noted that lumbar disc disease is a well-known cause of lower extremity radiculopathy. The examiner opined that the Veteran's fibromyalgia is less likely as not (less than 50/50 probability) caused by or a result of her service, noting that the disability was diagnosed in 2003 and the Veteran was never seen for it in service. This opinion was based on the Veteran's lay history. The examiner further opined that the fibromyalgia is as least as likely as not (50/50 probability) caused by or a result of her service-connected low back disability. The examiner noted that doctors do not know what causes fibromyalgia but it most likely involves a variety of factors working together, including genetics, infections, and physical or emotional trauma. The examiner cited the Veteran's report that her back pain has continued to worsen since 1987, and the initial insult was due to physical trauma of injuring the back in service; the examiner opined that the worsening of the back pain is considered a trigger for the fibromyalgia. The RO sought clarification of the October 2012 VA medical opinions and obtained an April 2013 records review and medical opinion. The reviewing physician cited the complete records from the Veteran's most recent [March 2013] VA treatment, October 2012 VA examination, April 2011 VA examination with June 2011 addendum opinion, several relevant cited X-rays from 2010 to 2012, and consultation reports from July 2011, September 2010, and June 2007. The reviewing physician cited the findings on May 2000 VA examination with impression of tension headaches, April 2000 treatment letter with nexus opinion relating the Veteran's right shoulder rotator cuff tendonitis and impingement to firing a machine gun while training with the National Guard, and May 2001 treatment letter supporting the Veteran's claims of pain near her eye since she was injured by a Venetian blind in 1985. The reviewing physician cited April 2000 lay statements from the Veteran's mother and sister noting her complaints about her shoulder, back, legs, ankles, feet, neck, headaches, and right eye. The April 2013 reviewing VA physician opined that it is less likely than not (less than 50 percent probability) that the following diagnosed disabilities were incurred in or caused by the Veteran's service: possible minimal degenerative change of the lunate triquetral articulation of the right hand; minimal degenerative changes of the left hand digits; bilateral carpal tunnel syndrome; claimed bilateral de Quervain's tendinitis; right rotator cuff tendinitis; right shoulder osteoarthritis; status post right acromioplasty; degeneration of the cervical intervertebral discs; osteoarthritis/spondylosis with Grade 1 anterolisthesis of C5 on C6 and C6 on C7; bilateral degenerative or traumatic arthritis of the feet; bilateral calcaneal spurs; bilateral lower extremity radiculopathy; bilateral ankle sprain with mild soft tissue swelling lover the lateral malleolar areas; and bilateral calcaneal spurs. The April 2013 reviewing physician further opined that it is at least as likely as not that the Veteran's claimed leg disability of bilateral lower extremity radiculopathy (mild L4, L5, S1 radiculopathies - based on subjective complaints) is proximately due to or the result of the Veteran's service-connected low back disability. The physician concurred with the October 2012 examiner's findings that the Veteran has had the claimed radicular symptoms since the onset of her back pain in 1987. The reviewing physician opined that it is less likely than not (less than 50 percent probability) that any of the other diagnosed disabilities listed above is proximately due to, the result of, or aggravated by the service-connected low back disability. For rationale, the reviewing physician noted that the left ankle injury documented in the Veteran's STRs was an acute self-limited minor injury with no evidence of an ongoing ankle problem, and none of the other listed disabilities claimed by the Veteran were evaluated or treated while she was on active duty. The reviewing physician cited the October 2012 VA examiner's findings regarding the wrists, bilateral carpal tunnel syndrome, de Quervain's tendinitis, and fibromyalgia. The reviewing physician also cited the June 2007 rheumatology findings that the Veteran had fibromyalgia well documented with diffuse total body pain, including in her neck, low back, arms, legs, and practically all of the muscles and joints in her body. The reviewing physician noted that many of the Veteran's pains are from her diagnosed fibromyalgia, as noted by the June 2007 rheumatologist, and explained that the etiology of fibromyalgia in current medical literature identifies a multitude of causes. The reviewing physician found no scientific basis from the literature to connect any of the Veteran's other above-listed disabilities other than the claimed lower extremity radiculopathy to her service-connected low back disability. The reviewing physician noted that degenerative joint disease or osteoarthritis in one location or joint is often associated with degenerative joint disease in other joints but it is not a causal relationship, explaining that the joints share the Veteran's genetic predisposition and lifestyle choices. The Veteran has also submitted VA treatment records showing findings similar to those on the VA examinations outlined above. It is not shown that any chronic disability manifested by pain and numbness in the arms and hands, and/or by joint pain in the shoulders, neck, legs, feet, and ankles became manifest in service and persisted, or that arthritis of any of these body parts or joints was manifested in the first postservice year. The Veteran's STRs do not contain any evidence of persistent complaints pertaining to any joint other than ankles during service, or any evidence of complaint, finding, treatment or diagnosis of a chronic disability regarding any joint during service. There is also no evidence of postservice continuity of ankle complaints. The Board notes that an October 2012 VA examiner found a number of these disabilities were at least as likely as not related to her military service. However, the opinion lacks probative value for various reasons, including: That the examiner's report suggests that the examiner was unaware of the distinctions between Federalized National Guard service (which is qualifying for VA benefits) and non-Federalized National Guard service (which is not), that the examiner was unaware of when the Veteran was on active duty/qualifying for VA benefits service (as in providing rationale for the opinion the examiner cites, in part, to onset of complaints in 1982-which the examiner apparently was led to believe was during a qualifying period of service when, if fact, it preceded the acknowledged qualifying service by three years); and that the examiner clearly relies on the Veteran's lay accounts (as well as those by her sister in a supporting statement) and those accounts are inconsistent with, and unsupported/contradicted by more contemporaneous data and self-serving, and therefore not credible. Accordingly, service connection for chronic disability manifested by pain and numbness in the arms and hands, and/or by joint pain in the shoulders, neck, legs, feet, and ankles, on the basis that it was incurred or aggravated in service, or on a presumptive basis (for arthritis as a chronic disease under 38 U.S.C.A. § 1137), is not warranted. Regarding the proposed secondary service connection theory of entitlement, the Board notes that some of the Veteran's complaints of pain have been determined to be from radiculopathy secondary to her service connected back disability. The Board also notes that both the October 2012 VA examiner and the April 2013 VA reviewing physician diagnosed bilateral lower extremity radiculopathy (mild L4, L5, and S1 radiculopathies) and opined that such radiculopathy is at least as likely as not related to the service-connected back disability. The Board finds no reason to dispute the opinions of the two VA medical professionals. Accordingly, the Board finds that all of the criteria for establishing service connection for radiculopathy of both lower extremities as neurological manifestations of the low back disability are met, and that secondary service connection radiculopathy of both lower extremities as a neurological manifestation of the low back disability is warranted. Regarding the further disabilities claimed, the Board finds that the preponderance of the evidence is also against the Veteran's alleged secondary service connection theory of entitlement to the benefits sought. On October 2012 VA examination and April 2013 VA records review and medical opinion (the reports of which the Board found adequate and probative), the examiners opined that the Veteran's complaints regarding her hands, wrists, arms, shoulders, neck, and ankles are unrelated to her service-connected back disability. The physicians noted the history of the claimed and diagnosed disabilities, and thoroughly explained the rationale for the opinions. The examiners provided further rationale for the opinions by identifying other etiological factors for the various complaints, including chronic degenerative changes and unrelated fibromyalgia. The examiners noted that a review of generally accepted medical literature found no support for the Veteran's alleged theories of causation. The Board finds this evidence highly probative in the matter at hand. Because there is no competent (medical opinion/treatise) evidence to the contrary with opinion supported by any explanation, the Board finds the October 2012 and April 2013 VA examiners' opinions to be persuasive. The Board notes the private physician's opinion relating the Veteran's shoulder complaints to her National Guard service. The Board reiterates that only Federalized National Guard service is qualifying for VA compensation benefits. The opinion notes onset of the shoulder disabilities at a time when the Veteran was not in Federalized service. Therefore, the opinion is without probative value. AS for the Veteran's own opinion that her other claimed chronic disabilities are due to her service-connected back disability, she is a layperson (with no demonstrated or alleged expertise in determining whether there is a nexus between arthritis of the spine with that of other joints); does not offer any probative medical opinion or cite to supporting medical treatise evidence; does not cite to any supporting factual data; and does not offer any explanation of rationale for her opinion. Therefore, her opinion on this question of causality (which is medical in nature and beyond lay observation) has no probative value. See Jandreau, supra, at 1372, 1377. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claims of service connection for chronic disabilities manifested by pain and numbness in the arms and hands and/or by joint pain in the shoulders, neck, legs, feet, and ankles. Hence, they must be denied. ORDER Service connection for radiculopathy of both lower extremities, as secondary to/neurological manifestations of a service connected low back disability, is granted. The appeal seeking service connection for chronic disabilities manifested by pain and numbness in the arms and hands, and by joint pain in the shoulders, neck, legs, feet and ankles is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs