Citation Nr: 1323449 Decision Date: 07/23/13 Archive Date: 08/01/13 DOCKET NO. 10-03 247 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for degenerative joint disease of the bilateral upper extremities. 2. Entitlement to service connection for degenerative joint disease of the bilateral lower extremities. 3. Entitlement to service connection for headaches, claimed as migraines. 4. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from October 1969 to October 1973. This appeal comes before the Board of Veterans' Appeals (Board) from a rating decisions by the Waco, Texas Regional Office (RO) of the United States Department of Veterans Affairs (VA). In a December 2008 rating decision, the RO denied service connection for arthritis of the upper and lower extremities. In a June 2010 rating decision the RO denied service connection for headaches, tinnitus, and a bilateral foot disability claimed as calluses, corns, and athlete's foot. The Veteran testified regarding the issues on appeal at a June 2011 Travel Board hearing. The hearing transcript is associated with the claims file. In August 2012, the Board remanded the issues on appeal to the RO via the VA Appeals Management Center (AMC), for the development of additional evidence. In a January 2013 rating decision the RO granted service connection for tinea pedis (athlete's foot) of both feet. That decision resolved the appeal for service connection for a bilateral foot disability, so that issue is no longer on appeal before the Board. With regard to the issues remaining on appeal, the Board is satisfied that there has been substantial compliance with the remand directives. The Board will proceed with review. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has reviewed both the Veteran's paper claims file and the Veteran's file on the Virtual VA electronic file system, to ensure a total review of the evidence. FINDINGS OF FACT 1. Service-connected left and right shoulder strain did not cause or aggravate left and right shoulder degenerative joint disease that was found many years after service. 2. The Veteran did not have left or right elbow injury, disease, or symptoms during service. 3. Service-connected disabilities did not cause or aggravate any current arthritis or other disorder of the left or right elbow. 4. Degenerative joint disease has not been found in either of the Veteran's wrists nor in any of his hand or finger joints. 5. Degenerative joint disease has not been found in either of the Veteran's hips. 6. Recurrent left and right knee bursitis reported during service has not caused any current disability. 7. Degenerative joint disease has not been found in either of the Veteran's knees. 8. The Veteran did not have left or right ankle injury, disease, or symptoms during service. 9. Service-connected disabilities did not cause or aggravate any current arthritis or other disorder of the left or right ankle. 10. Degenerative joint disease has not been found in any of the Veteran's foot or toe joints. 11. The Veteran had recurrent headaches during service that continued after service. 12. The Veteran was exposed to noise during service, but he reports first experiencing tinnitus many years after service. CONCLUSIONS OF LAW 1. Degenerative joint disease of the bilateral upper extremities was not incurred or aggravated in service, is not presumed to be service-connected, and is not proximately due to, the result of, or aggravated by any service-connected disabilities. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. Degenerative joint disease of the bilateral lower extremities was not incurred or aggravated in service, is not presumed to be service-connected, and is not proximately due to, the result of, or aggravated by any service-connected disabilities. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 3. A disorder manifested by recurrent headaches was incurred in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 4. Current tinnitus was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2013)) redefined VA's duty to assist a claimant in the development of a claim for VA benefits. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has stated that the requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). Also, in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that that the VLJ who conducts a Board hearing fulfill duties to (1) fully explain the issues and (2) suggest the submission of evidence that may have been overlooked. The RO provided the Veteran VCAA notice in letters issued in April 2008 and January 2010, before the initial unfavorable decisions on the issues on appeal. Those letters addressed the information and evidence necessary to substantiate claims for service connection and informed the Veteran how VA assigns disability ratings and effective dates. The letters also addressed who was to provide the evidence. In the June 2011 Travel Board hearing the Veteran was assisted by an accredited representative from the Texas Veterans Commission. The undersigned Acting VLJ explained the issues, and noted that the record would be held open for the Veteran to submit additional information in support of his claim for service connection for tinnitus. The Veteran and his representative stated where the Veteran had received treatment for the conditions addressed by the appeals. The Veteran and his representative asserted that original or additional VA medical examinations should be performed regarding the Veteran's claims for service connection for tinnitus and headaches. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. The Board therefore finds that, consistent with Bryant, the Acting VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and that any error provided in notice during the Veteran's hearing constitutes harmless error. The claims file contains the Veteran's service treatment records, post-service treatment records, VA examination reports, and a transcript of the June 2011 Travel Board hearing. The Veteran has had VA medical examinations that adequately addressed the claims on appeal. In the August 2012 remand the Board instructed that additional VA medical records be obtained and that additional VA examinations be performed. Additional VA medical records were associated with the Veteran's paper and electronic files. In November 2012 the Veteran had VA examinations addressing his claims, including the appeals for service connection for arthritis of the upper and lower extremities and for headaches. The Board finds that there has been substantial compliance with the remand directives. The Board therefore concludes that no additional remand is required. See Stegall v. West, 11 Vet. App. 268 (1998). The Board finds that the Veteran was notified and aware of the evidence needed to substantiate the claims on appeal, as well as the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran has actively participated in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process, and he has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication nor to have caused injury to the Veteran's interests. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless, and does not prohibit consideration of the claims on the merits. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Degenerative Joint Disease of the Extremities The Veteran is seeking service connection for arthritis of the upper and lower extremities. He essentially contends that he has arthritis in those areas that began during service or was caused or aggravated by service-connected disabilities. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection also may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis, may be established based upon a legal presumption by showing that it manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury, or for aggravation of a non-service-connected disability by a service-connected disability. 38 C.F.R. § 3.310. The Court has explained that, in general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, subsequent manifestations of the same chronic disease or injury at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative means of establishing service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran's musculoskeletal disorders for which VA has established service connection are low back strain, cervical spine strain, left shoulder strain, and right shoulder strain. Service connection is also established for a right thigh scar residual to a wound during service. During service the Veteran had treatment from 1970 forward for low back pain. In some treatment visits he reported that his low back pain radiated down his left lower extremity to the thigh or knee. In September 1971 he sustained a laceration for the right thigh. In a June 1973 medical history he reported having had bursitis of the shoulders and knees in 1970. He indicated that the bursitis was not treated and that it resolved. After service, in a June 1978 VA medical examination, the Veteran reported that during service in 1970 he experienced bursitis in both shoulders and both knees. He stated that the bursitis was recurrent. The examiner observed that the Veteran's left thigh flexion lacked about 10 degrees of normal and that his right thigh flexion lacked about 5 degrees of normal. He had motion of both knees from 0 to 140 degrees. Both shoulders had full ranges of motion. The examiner's musculoskeletal diagnoses were chronic lumbosacral back strain with pain, and history of recurrent bursitis of both shoulders and both knees. The claims file contains records of VA treatment of the Veteran from as early as the late 1970s. In 1978 through 1982 he was seen for low back pain. In November 1979 he reported that low back pain radiated into both lower extremities. A treating clinician found normal strength in the lower extremity muscles. In a December 1980 statement the Veteran reported that his low back pain radiated into both legs and caused him to limp. On VA examination in June 1981 the Veteran reported that low back pain radiated to both legs. He was able to flex and extend both knees to full ranges of motion. Internal and external rotation of both hips were normal. On VA examination in April 1983 the Veteran reported that his low back pain radiated into his right lower extremity. In 1989 and 1990 the Veteran had VA treatment for low back pain. He reported occasional radiation of pain into the left thigh and knee. On VA examination in February 1991 he reported back pain with numbness in the left leg and aching pain in the right thigh. The examiner found limitation of motion of the lumbar spine with paralumbar spinal muscle tenderness. There was no significant limitation of motion of the cervical spine, shoulders, elbows, wrists, fingers, knees, ankles, or feet. VA treatment records from 1991 through 1994 reflect ongoing low back pain and some reports of right thigh pain. On one occasion in January 1992 the Veteran reported right upper arm pain. On VA examination in April 1993 the Veteran's upper and lower extremities were essentially normal. In VA treatment in the late 1990s the Veteran reported ongoing low back pain. In 1999 he reported pain in his low back and his left shoulder. In 2000 he reported that his low back pain radiated into his left leg. In VA treatment in 2006 through 2008 the Veteran reported pain in his back. In October 2006 he indicated that he had pain in his joints and his back. From 2007forward he has reported pain in both shoulders. In 2007 a treating clinician listed an impression of arthralgia. In April 2007 the Veteran reported having achy legs. In July and August 2007 he had physical therapy. In February 2008 the Veteran saw private physician J. L. A., M.D. The Veteran reported that a VA physician told him that he had arthritis. The Veteran reported longstanding pain in his lower back and more recently pain in his upper back. Dr. A. stated that x-rays showed moderate osteoarthritic changes. Dr. A.'s impression was chronic back pain. In March 2008 the Veteran submitted a claim for service connection for arthritis of the upper and lower extremities. In July through October 2008 the Veteran had VA kinesiotherapy to strengthen his back to address arthritis of the back and shoulders. He had VA examinations of the joints and spine in October 2008. He reported chronic pain in his thoracolumbar spine, neck, and both shoulders. The examiner found evidence of pain in both shoulders and increased pain at the extremes of the ranges of motion. The examiner observed that the Veteran's gait was normal. The examiner provided impressions of bilateral shoulder strain and cervical spine strain. In a February 2009 VA spine examination the Veteran reported low back pain that travelled to the upper back. The examiner diagnosed chronic intermittent lumbosacral strain and degenerative joint disease of the lumbosacral spine. In a June 2009 VA examination the Veteran reported a history of low back pain since 1970 and neck and bilateral shoulder pain since 2004. In an August 2009 statement the Veteran contended that arthritis of his upper and lower extremities manifested either directly as a result of his active service or as secondary to his service-connected conditions. In a January 2010 statement he contended that arthritis of the upper and lower extremities manifested during his service. In VA treatment in 2010 the Veteran reported numbness in fingers in his left hand. Testing showed ulnar nerve entrapment. Treatment records show ongoing shoulder symptoms through 2011. In the June 2011 Travel Board hearing the Veteran reported that he had arthritis in his hips, but not in his knees. The Veteran had VA medical examinations in November 2012. The examiner reported having reviewed the Veteran's claims file. The Veteran reported a history of pain in both shoulders. The examiner found degenerative joint disease of the left and right acromioclavicular joints. The examiner noted that x-rays from the late 1990s did not show degenerative joint disease in the shoulders, and that x-rays from 2009 showed degenerative joint disease in both shoulders. The examiner noted that the Veteran had a long work history as a nurse's aide and janitor. The examiner expressed the opinion that it is more likely than not that the degenerative joint disease in the Veteran's shoulders is related to post-service employment and age and not to his service-connected shoulder strains. The examiner also opined that the shoulder arthritis is not caused by and has not been aggravated by the Veteran's service-connected neck and back disorders. The Veteran reported having soreness and popping in his elbows at times. He denied injury or trauma to the elbows. He stated that in 2008 or 2009 he experienced numbness in the fingers of his left hand and was diagnosed with ulnar nerve entrapment syndrome. On examination extension of the left and right elbows was less than full, ending at 10 degrees. Both elbows had normal muscle strength. The examiner provided a diagnosis of left ulnar nerve entrapment. The examiner expressed the opinion that it is less likely than not that the Veteran's elbow complaints are proximately due to or the result of any service-connected condition. The examiner elaborated that the Veteran's elbow conditions, whether or not he has elbow arthritis, are not related to service-connected conditions of his neck, back, and shoulders and have not been permanently aggravated by those conditions. The Veteran denied having had any injuries, trauma, arthritis symptoms, or arthritis diagnosis involving either wrist or any of the joints in his hands and fingers. He denied any hand symptoms other than left hand numbness related to ulnar nerve entrapment symptoms. The examiner concluded that the Veteran did not have any disorder of the wrists, hands, or fingers. The Veteran denied any current symptoms or problems with his hips or knees. He denied any history of injury of either hip or knee or of diagnosis of any hip or knee condition. The examiner concluded that the Veteran did not have any hip or knee disorder. The Veteran reported a one year history of his ankles giving out at times. In each ankle he had plantar flexion to 25 degrees (compared to a normal endpoint of 45 degrees) and had dorsiflexion to the normal endpoint of 20 degrees. There was no evidence of pain with motion nor of further reduction of function after repeated motions. There was no evidence of ankle tenderness, muscle weakness, or laxity. The Veteran did not use any assistive device for walking. The examiner concluded that the Veteran did not have any disorder of either ankle. The examiner expressed the opinion that that it is less likely than not that the Veteran's ankle complaints are proximately due to or the result of any service-connected condition. The examiner elaborated that the Veteran's ankle conditions, whether or not he has ankle arthritis, are not related to service-connected conditions of his neck, back, and shoulders, and have not been permanently aggravated by those conditions. The Veteran reported a history of bilateral athlete's foot. He did not report any history of musculoskeletal symptoms in either foot, and the examiner did not find evidence of any musculoskeletal disorder of either foot. The Veteran does not report, and no medical records show, diagnosis during the year following separation from service of degenerative joint disease in either shoulder, elbow, or wrist, any of the hand and finger joints, either hip, knee, or ankle, or any of the foot or toe joints. Thus there is not a basis to presume service connection for degenerative joint disease in any of the joints of the Veteran's upper or lower extremities. Service connection is established for strain of the left and right shoulders. Degenerative joint disease has been found in each shoulder, but was not found until many years after service. The VA physician who examined the Veteran in 2012 opined that it is less likely than not that the current degenerative joint disease is causally related to service. The examiner has the requisite medical expertise to provide a medical opinion regarding the etiology of a disorder, and the examiner had sufficient facts and data on which to bases his conclusions. The Board therefore finds that examiner's opinion to be of great probative value. The preponderance of the evidence is against the incurrence of shoulder degenerative joint disease during service. The 2012 VA examiner also opined, based on the history in this case, that it is less likely than not that current degenerative joint disease of the shoulder was caused or aggravated by the service-connected shoulder strain or cervical spine strain. The Veteran asserted that his service-connected disabilities caused upper and lower extremity arthritis. As the Veteran is a layperson, without medical expertise, he is not capable of making medical conclusions, and his statements regarding medical causation are not competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Lay statements may be competent to support a claim for service connection by supporting the occurrence of events or the presence of disability or symptoms that a lay person is capable of observing. Id., see also Buchanan v. Nicholson, 441 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support the presence of disability even where not corroborated by contemporaneous medical evidence). Disorders involving degenerative changes are, however, complex disorders which require specialized training and objective clinical findings, such as X-rays, for a determination as to diagnosis and causation. Therefore they are not susceptible of lay opinions on etiology. The Veteran's statements therefore cannot be accepted as competent medical evidence on that question. The examiner's opinion regarding secondary causation or aggravation is competent evidence, and outweighs any assertions by the Veteran. The preponderance of the evidence thus is against secondary causation or aggravation of left and right shoulder arthritis by service-connected shoulder strain or neck strain. In 2012 the Veteran reported intermittent soreness and popping in his elbows. There is no evidence that he had any left or right elbow injury or symptoms during service nor within many years after service, however, based on the Veteran's report left ulnar nerve entrapment became symptomatic no earlier than 2008 or 2009. Thus, medical records do not indicate, and the Veteran has not stated, that he had elbow symptoms during service or for many years after. Therefore, the evidence does not help to show that any current elbow disorder was incurred in service. The Veteran asserts that service-connected disabilities caused or aggravated current left and right elbow symptoms. As he is a layperson his statement is not competent evidence regarding medical causation. The 2012 VA examiner competently opined that the Veteran's service-connected back, neck, and shoulder disabilities did not cause or aggravate any current left or right elbow disorders. The preponderance of the evidence is against secondary service connection for left or right elbow disorders including claimed degenerative joint disease. The Veteran does not contend that he has degenerative joint disease in either wrist or any joint in his hands or fingers. Medical records from during and after service do not contain any diagnosis of degenerative joint disease in any of those joints. As the record does not contain evidence that the Veteran has degenerative joint disease in the wrist, hands, or fingers, service connection for such disease is not warranted. See Shedden, supra, at 1167. In treatment for his low back pain, the Veteran has sometimes reported pain radiating into one or both lower extremities. His service treatment records do not address any symptoms specifically involving either hip. After service, in June 1978, a VA examiner noted less than normal flexion of each thigh. At that time the Veteran was not complaining of hip symptoms, and the examiner did not diagnose any disorder of the hips. Post-service treatment records do not reflect complaints or findings specifically addressing either hip. In the 2011 Travel Board hearing the Veteran indicated that he had bilateral hip arthritis. In the 2012 VA examination, however, he reportedly denied any history of injury, symptoms, or diagnosis involving either hip. The Veteran has stated that he has arthritis in his hips, but as a layperson he is competent to report hip symptoms but not to diagnose any underlying disorder or disease associated with symptoms. There is no indication that x-rays of the Veteran's hips have been taken. This is not surprising as there is no record of him relating any hip symptoms to clinicians. In any case, the record lacks competent evidence that the Veteran has degenerative joint disease in either hip. In the absence of evidence that the Veteran currently has such disease, service connection for such disease is not warranted. See Shedden, supra, at 1167. Around the time of separation from service the Veteran reported a history of bursitis in both knees. He indicated that the bursitis had resolved. A few years after service, in a June 1978 VA examination, the Veteran reported a history of recurrent bilateral knee bursitis. The examiner found that the Veteran's knees had full ranges of motion. While the Veteran reports that lower extremity pain sometimes accompanies his low back pain, records of medical treatment from the 1980s forward do not reflect any complaints of symptoms specifically involving either knee. In his 2011 Travel Board hearing the Veteran stated that he had arthritis in his hips but did not have arthritis in his knees. In the 2012 VA examination the Veteran denied any history of knee injury, diagnosis, or symptoms. The record does not contain competent evidence that the Veteran has degenerative joint disease in either knee. Therefore service connection for such disease is not warranted. See Shedden, supra, at 1167. During service the Veteran did not report any symptoms specifically involving his ankles. He did not report ankle symptoms over the years following service. In a February 1991 VA examination there was no significant limitation of motion of either ankle. On VA examination in 2012 he reported recent giving out of the ankles. The examiner found that each ankle had less than full plantar flexion. There is no report that x-rays have been taken of the Veteran's ankles, and there is no record of any clinician diagnosing arthritis in either of the Veteran's ankles. So it is not clear whether there is arthritis in the Veteran's ankles. The Veteran recalls a physician telling him that he has arthritis at least in some joints in his body, and he contends that he has current bilateral ankle arthritis that began during service or was caused or aggravated by service-connected disabilities. The Veteran has not stated, however, that he had symptoms in his ankles during service. The Veteran's accounts and the medical records do not indicate that he had symptoms in his ankles earlier than many years after service. In the absence of evidence of ankle injury, disease, or symptoms during service, the preponderance of the evidence is against current ankle symptoms being directly related to service. As noted above, the opinion of the 2012 VA examiner is of great probative value because he has the requisite medical expertise to provide a medical opinion regarding the etiology of a disorder and he had sufficient facts and data on which to bases his conclusions. That examiner concluded that it is less likely than not that the Veteran's current ankle complaints are proximately due to or the result of any service-connected conditions, or have been permanently aggravated by any service-connected conditions. Whether disorders have caused or aggravated other disorders is a complex medical issue that requires specialized training and is not susceptible of lay opinion. The Veteran's lay assertions that service-connected disabilities caused or aggravated current ankle problems is not competent evidence regarding those questions. Thus, the preponderance of the evidence is against both direct and secondary service connection for arthritis or other current disability of the left or right ankles. The service treatment records do not reflect any report of musculoskeletal symptoms in either foot. After service through the present the Veteran has not reported any musculoskeletal symptoms in either foot, and no clinician has found evidence or arthritis or any other musculoskeletal disorder in either foot. As the record does not contain evidence that the Veteran has degenerative joint disease in either foot, service connection for such disease is not warranted. See Shedden, supra, at 1167. Headaches The Veteran reports that he had recurrent headaches during service and has continued to have recurrent headaches through the present. During service he was seen at a dispensary in November 1970 with a three day history of steady substernal chest pain and intermittent frontal headache. He reported feeling dizzy and fuzzy. A treating clinician provided an impression of pleurisy. In June 1973 the Veteran completed a medical history in conjunction with an examination for separation from service. He checked yes for a history of frequent or severe headaches. He indicated that he had severe headaches treated with aspirin with good results and with no complications or sequela. In April 1978, a few years after his service, the Veteran submitted a claim for service connection for a back condition. In a June 1978 VA medical examination the Veteran reported a history of recurrent headaches. The claims file contains records of VA treatment from the late 1970s forward. In June 2006 the Veteran reported having had a headache which he described as more tight than throbbing. On the same visit he reported elevated blood pressure readings and a couple of bouts of dizziness. In January 2010 the Veteran submitted a claim for migraine headaches. He contended that the headaches manifested during his active service. In VA treatment in May 2011 the Veteran reported having chronic mild headaches. He stated that he took medication that was effective. He indicated that he had experienced these headaches for the last 30 years, that this was not a new disorder. The treating clinician's impression was chronic tension headaches. Subsequent VA treatment notes from 2011 and 2012 include history of chronic tension headaches in the list of the Veteran's problems. In the June 2011 Travel Board hearing the Veteran indicated that he had headaches during service and continued to have them through the present. He stated that he was on medication to address headaches. He reported that some of his headaches were not very bad and some caused sickness and vomiting. He stated that earlier in the history of his headaches he took nonprescription medication for them, and that in the most recent three to four years he received prescription medication for them from VA. He indicated that a VA physician told him that the medication he prescribed for arthritis was also good for his headaches. On VA examination in November 2012 the Veteran reported that he had headaches during service. He stated that presently he had headaches that lasted up to three or four days and occurred every one or two months. He stated that the headaches were accompanied by nausea and occasionally vomiting. He reported that he took Naproxen for the headaches. The examiner found that the Veteran did not have a headache condition. The examiner expressed the opinion that it is less likely than not that claimed current headaches were incurred in service or caused by claimed headaches during service. The examiner stated that the Veteran's service treatment records did not contain any clinic visits that referred to treatment for headaches. The examiner noted the history of headaches recorded at the Veteran's separation examination. The examiner stated that the Veteran reported having had no workup or diagnosis of his headaches since service. The examiner explained that, because there were not more records of headaches during service, nor any workup after service, it is less likely than not that the Veteran's current headaches are related to the headaches described at separation from service. The May 2011 VA treatment notes are medical evidence of a current headache disability. Those records support the Veteran's reports that he currently has recurrent headaches. Both the November 1970 treatment note and the June 1973 service separation history show that during service the Veteran reported having headaches. That evidence is adequate to show that during service the Veteran experienced headaches. Headaches are subjectively experienced and not readily objectively observable. A layperson is competent to report and recall headache symptoms that he experiences. After service in 1978, 2006, and 2011 clinicians recorded the Veteran's reports that he had recurrent headaches. Those records help to document the Veteran's account that he has continued to experience headaches after service. The VA physician who examined the Veteran in 2012 opined that it is less likely than not that the headaches the Veteran currently reports are related to the headaches he reported during service. That examiner explained that opinion based on the lack of additional evidence of headaches during and after service. In that opinion, however, the examiner did not mention the November 1970 service outpatient treatment, the June 1978 VA medical examination report, or the May 2011 VA treatment report. The examiner's failure to discuss relevant medical records reduces the value of or even invalidates his opinion against service connection, especially as that opinion is based on a stated lack of supporting medical records. A medical opinion based on an inaccurate factual predicate is of no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Board finds that the Veteran's accounts, some in medical records, of headaches during and since service support the existence of a headache disorder during and since service. The VA examiner's opinion does not effectively oppose such a finding because the examiner did not consider some of the significant records. Resolving reasonable doubt in the Veteran's favor, the headache reports during and after service adequately support a nexus between headaches during and after service. As there is also valid evidence of a current headache disorder and of headaches during service, the record supports service connection for the Veteran's current headache disorder. Tinnitus The Veteran essentially contends that he has tinnitus that is attributable to noise exposure during service or was caused or aggravated by bilateral hearing loss. The Veteran previously sought service connection for bilateral hearing loss. The RO denied service connection for bilateral hearing loss. On appeal, the Board denied service connection for bilateral hearing loss. As service connection is not established for hearing loss, service connection for tinnitus as secondary to hearing loss cannot be established. In a June 1973 service medical history the Veteran reported a history of ear ache. That history, and the remainder of his service treatment records, however, do not show any complaint of tinnitus. A June 1978 VA examination report is silent for reports or tinnitus or other ear-related complaints. The other assembled post-service VA and private medical records are silent as to any report of tinnitus. In January 2010 the Veteran submitted a claim for service connection for several conditions including tinnitus. He contended that he had tinnitus that manifested during his active service or was secondary to bilateral hearing loss. In a May 2010 VA audiology examination the Veteran reported that his military duties were in the security police. He stated that he had exposure to noise from artillery, aircraft, engines, and gunfire, and that he used hearing protection most of the time. He indicated that after service he did not have occupational noise exposure but had recreational noise exposure from power tools and lawn equipment. He reported that from 1970 forward he noticed gradually progressing difficulty hearing speech, television, and speech via the telephone. He indicated that he was unsure of the specific circumstances of the onset of his tinnitus. He stated that beginning in the last five to six years he had experienced frequent bilateral tinnitus of mild loudness. He stated that the tinnitus was high-pitched, occurred two to three times a week, and lasted two to three minutes each time. The examiner stated that, because the Veteran's service treatment records did not show complaints of tinnitus, and because his tinnitus became manifest after his service, it is less likely than not that his current tinnitus was caused by acoustic trauma during service. In the June 2011 Travel Board hearing the Veteran noted that the VA audiologist who examined him in May 2010 concluded that he was exposed to noise during service. The Veteran related an intention to obtain a medical opinion regarding the etiology of his current tinnitus. The Board held the record open for 60 days to allow the Veteran to submit such opinion. Tinnitus is experienced subjectively. The Veteran's reports of recent tinnitus are sufficient to establish that he has current tinnitus. While there is evidence of noise exposure during service, there is no lay or medical evidence that the Veteran experienced tinnitus during service. Records from the time of service do not show that he reported tinnitus during service. Equally importantly, the Veteran has not stated at any time that he experienced tinnitus during service. In the 2010 VA examination he reported that he noticed tinnitus beginning five or six years before 2010, which is many years after his 1973 service separation. The VA examiner opined that it is less likely than not that the Veteran's current tinnitus is related to his noise exposure during service. The examiner's opinion is of great probative value because the examiner has the requisite expertise to provide an opinion regarding the etiology of an audiological disorder and she had sufficient facts and data on which to bases her conclusions. The preponderance of the evidence is against onset of tinnitus in service and against a causal relationship between the Veteran's noise exposure in service and the tinnitus that became noticeable long after service. The Board therefore denies service connection for tinnitus. ORDER Entitlement to service connection for degenerative joint disease of the bilateral upper extremities is denied. Entitlement to service connection for degenerative joint disease of the bilateral lower extremities is denied. Entitlement to service connection for recurrent headaches is granted. (CONTINUED ON NEXT PAGE) Entitlement to service connection for tinnitus is denied. ____________________________________________ THOMAS D. JONES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs