Citation Nr: 1324295 Decision Date: 07/31/13 Archive Date: 08/07/13 DOCKET NO. 10-08 083 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to service connection for a low back disability, to include as secondary to service-connected left ankle injury residuals. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD M. Sorisio, Counsel INTRODUCTION The Veteran served on active duty from April 1987 to March 1993. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Lincoln, Nebraska Department of Veterans Affairs (VA) Regional Office (RO). In February 2010, the Veteran requested a video conference hearing before the Board. In a June 2011 statement, the Veteran withdrew his hearing request. In April 2012, the Board referred the case to the Veterans Health Administration (VHA) for an advisory medical opinion. In July 2012, the Board sought clarification of the VHA advisory opinion it received in response to its April 2012 request. In January 2013, the Board referred the case to an Independent Medical Expert (IME) for a further advisory medical opinion. In April 2013, the Veteran submitted additional evidence. In June 2013 written argument, the Veteran's representative waived initial RO consideration of such evidence. FINDING OF FACT The Veteran's current low back disability is not related to an event or injury in service and is not caused or aggravated by service-connected left ankle injury residuals. CONCLUSION OF LAW Service connection for a low back disability is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION A. 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 (West 2002 & Supp. 2012); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA applies to the instant claim. 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. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran was advised of VA's duties to notify and assist in the development of his service connection claim. A May 2009 letter provided him with notice of the evidence necessary to substantiate his claim for direct service connection. Although he did not receive notice of what was necessary to substantiate a secondary service connection claim prior to the initial August 2009 rating decision, since he did not raise that theory of entitlement until May 2011, a June 2011 letter provided notice of the evidence necessary to substantiate the claim based on this theory. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Both the May 2009 and June 2011 letters also explained the evidence VA was responsible for providing, the evidence he was responsible for providing, and informed him of disability rating and effective date criteria. An August 2011 Supplemental Statement of the Case (SSOC) readjudicated the matter after the Veteran received compliant notice, he and his representative responded to the notice, 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). Regarding VA's duty to assist, all relevant evidence necessary for an equitable resolution of the issue on appeal has been identified and obtained, to the extent possible. The Veteran and his representative have not identified any outstanding relevant evidence. In June 2011, the Veteran appeared for a VA examination to assess his low back disability. This examination included all necessary testing, physical examination of the Veteran, and review of his claims file. The examiner provided a thorough opinion with accompanying rationale on the question of whether the low back disability was caused or aggravated by the service-connected residuals of a left ankle injury. Thus, when reading the examination report as a whole, the Board finds that it is adequate to assess the secondary service connection theory of entitlement. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (finding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (stating that a VA examination report "must be read as a whole" to determine an examiner's rationale). The examiner, however, did not provide an opinion on whether the low back disability was related to the Veteran's service. Therefore, the Board finds that the VA examination was not adequate for rating purposes on the theory of direct service connection. In order to address this insufficiency, in April 2012, the Board requested an advisory medical opinion from a VHA specialist. In June 2012, the Board received an opinion that was inadequate for rating purposes and, in July 2012, requested further clarification of this opinion from the VHA specialist. However, the October 2012 clarifying opinion was also inadequate for rating purposes. These opinions were inadequate as they did not contain clear rationales. To ensure the record contained an adequate opinion regarding direct service connection the Board sought a further opinion from an IME in January 2013. In February 2013, the Board received an opinion from an IME that is adequate for rating purposes as the specialist reviewed the Veteran's claims file and provided a thorough response with rationale to the question asked by the Board. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (requiring substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion). Accordingly, VA's duties to notify and assist have been met and appellate review may proceed without prejudice to the Veteran with respect to his claim. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). B. Legal Criteria, Factual Background, and Analysis The Veteran seeks service connection for a low back disability. Specifically, he contends that his current low back disability directly resulted from duties performed during his service, or, in the alternative, that his low back disability is a result of his service-connected left ankle injury residuals. The Board will address these theories of entitlement in turn. Service Connection on a Direct Basis A Veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). A March 1987 entrance examination is negative for notation of a low back disability. Therefore, the Veteran is presumed sound as to a low back disability. However, a September 1990 service treatment record reflects that the Veteran reported having experienced a lifting injury to his lower back prior to service in 1986, while lifting a trailer. The Board recognizes that lay statements may be capable of constituting clear and unmistakable evidence to rebut the presumption of soundness. See Doran v. Brown, 6 Vet. App. 283, 286 (1994); see also Harris v. West, 203 F.3d 1347, 1351 (Fed. Cir. 2000) ("All that [38 U.S.C. § 1111] requires is that the evidence, whatever it may be, must lead, clearly and unmistakably, to the conclusion that the injury or disease existed before the veteran entered the service."). Although the Veteran is competent to provide evidence regarding observable symptoms and injuries he experienced prior to service, his medical history report does not clearly indicate that a chronic low back disability began before service. It does not elucidate whether he incurred a disability or any residuals from the lifting injury, the course of treatment, or any other factors that may enable the Board to gauge any relevant information as to the preexistence of a low back disability. Thus, the evidence does not undebatably show that he had a preexisting chronic low back disability. As such, the above evidence is not clear and unmistakable and is insufficient to rebut the presumption of soundness. See Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (explaining that clear and unmistakable evidence "cannot be misinterpreted and misunderstood, i.e., it is undebatable" (quoting Vanerson v. West, 12 Vet. App. 254, 258-59 (1999))). Because the presumption of soundness has not been rebutted, the claim is one of service connection, without consideration of aggravation of a pre-existing condition. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. A disorder may be service connected if the evidence of record shows that the Veteran currently has a disorder that was chronic in service or, for certain chronic diseases detailed in 38 C.F.R. § 3.309(a), that was seen in service with continuity of symptomatology demonstrated thereafter. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the continuity of symptomatology provisions of 38 C.F.R. § 3.303(b) only apply to a chronic disease listed in § 3.309(a)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for a claimed disorder, the following must be shown: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Where a Veteran served 90 days or more during a period of war or during peacetime service after December 31, 1946, and arthritis, as a chronic disease, becomes manifest to a degree of 10 percent or more within one year from the date of termination of such service, such disease shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). If a condition listed as a chronic disease in § 3.309(a) is noted during service, but is either shown not to be chronic or the diagnosis could be legitimately questioned, then a showing of continuity of related symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1336. In the instant case, there is medical evidence demonstrating that the Veteran has a current low back disability. Specifically, a June 2009 private medical record from Regional West Physicians Clinic reflects diagnoses of lumbar spondylosis with mechanical low back pain and facet degenerative joint disease in the lower segments of the lumbar spine. On June 2011 VA examination the examiner diagnosed lumbosacral degenerative disc disease. Therefore, the first element of service connection is met. In May 2009, February 2010, and August 2011 statements, the Veteran alleged that his low back disability was due to climbing ladders on-board an air craft carrier, performing preventative maintenance of radars, and repairing electronic equipment in tight areas, all during his time in service. He also alleged that, while stationed on the USS Constellation, he was responsible for ensuring all Operation spaces had a working fire extinguisher. He reported having to continuously replace fire extinguishers, weighing 50 pounds each, for a year, due to their misuse. The Veteran's DD Form 214 lists his military occupational specialties as Radar Technician and CATC DAIR Maintenance Technician. Medical history reports from 1991, 1992, and 1993, contained in the Veteran's service treatment records, are silent for low back-related complaints. Although there is no evidence of low back complaints during service, the Board finds the Veteran's statements that his military occupational specialties required heavy lifting and working in tight spaces to be competent and credible as these duties are consistent with the circumstances of his service. Therefore, the evidence shows an event in service and the second element of service connection is met. What remains to be established is that the Veteran's low back disability is related to the heavy lifting and work he performed in service. Multiple medical opinions and lay witness statements address this question. When evaluating the evidence of record, the Board must analyze its credibility and probative value, account for evidence which it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the Veteran. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Although the Board may appropriately favor the opinion of one competent medical authority over another, see Wensch v. Principi, 15 Vet. App. 362, 367 (2001), it must consider and weigh all medical evidence, keeping in mind the command of Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), that the benefit of the doubt in resolving such issues shall be given to the Veteran. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. An August 2003 private treatment note from Dr. B.P. reports that in July 2003 the Veteran suffered an episode of severe muscle spasms in his low back while performing his normal post-service work duties as an electrician. The Veteran reported that this incident resulted in continued symptoms of sometimes incapacitating pain in his low back and right leg. Dr. B.P. noted that the Veteran had a ruptured disc on the left side at L5-S1. He provided an impression of low back pain and right lower extremity pain, due to degenerative disc disease of the lumbar spine. Dr. B.P. opined that the Veteran's symptoms were directly related to the July 2003 work-related injury. He further commented that he was sure the Veteran had pre-existing degenerative disc disease of the lumbar spine which was exacerbated by the work-related injury. Although this opinion indicates that the Veteran had degenerative disc disease prior to the July 2003 work-related injury, it does not indicate when degenerative disc disease had its onset. Therefore, the opinion does not weigh either in favor of or against the Veteran's claim and has no probative value on the question of whether his current low back disability is related to his service. A September 2009 statement from the Veteran's spouse reports that the Veteran has had continuous and worsening back pain since his discharge from active duty. A December 2009 statement from the Veteran's father asserts that after service, the Veteran began taking over-the-counter pain pills for his back and had difficulty lifting heavy equipment. On June 2011 VA examination, the Veteran reported that he began experiencing soreness in his back around 1991 and that it progressed through the years. In a June 2012 opinion and October 2012 addendum opinion, Dr. U.S., a physician from the VHA, opined that she could not conclude that the Veteran's low back disability was a consequence of his military service. She stated that "it appears to be the sequela of a baseline predilection for degenerative disease and obesity as much as events that occurred after leaving the military." Dr. U.S. indicated that she reviewed the evidence of record, including the lay statements and the August 2003 opinion from Dr. B.P.; however, she did not provide a rationale for her conclusion that the Veteran's low back disability is more likely due to events after service and a predilection for degenerative disease and obesity. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the conclusions to the supporting data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (providing that a medical opinion must support its conclusion with an analysis that the Board can consider and weigh against any contrary opinions). As these opinions do not contain such an explanation, the Board places little weight of probative value on them. A January 2013 opinion from an IME in orthopaedic spine surgery provides a thorough history and discussion of the Veteran's low back disability, including discussing the pertinent medical records, the Veteran's lay statements, and lay statements from the Veteran's spouse and father. Based on this discussion, the examiner opined that it was less likely than not that the Veteran's current low back disability is related to an event or injury in service and that it is more likely than not related to an incident that occurred in 2003. He indicated that the Veteran had no convincing documented evidence of low back problems during or after service. He noted the Veteran's history of his work in service, but indicated that there was not a documented injury that explained any sort of back problems beyond what would normally be expected in someone's back given the natural degenerative process/aging process. The IME explained that, in his opinion, degenerative disc disease is a chronic condition that is more related to someone's genetic susceptibility than to someone's prior occupational history. He discussed seeing patients with severe degenerative disc disease who have no history of any heavy duty or heavy work activities, as contrasted to patients who have minimal to no degenerative disc disease, but have a history of heavy work activities. He indicated that genetics and lifestyle choices, such as smoking, can play a big role in the development of degenerative disc disease. He acknowledged that occupational exposure may increase or exacerbate degenerative disc disease, but there was no documented evidence of such in the Veteran's file. The IME further noted that the radiculopathy and ruptured disc that was noted in 2003 would explain the Veteran's back and leg pain. He emphasized that having a ruptured disc and radiculopathy and increased back and leg pain were not related to preexisting degenerative disc disease. He thus concluded that the record did not contain any compelling evidence of an injury or exacerbation of the Veteran's back during service and that he likely has ongoing degenerative disc disease that is more likely than not related to the natural history of that condition and the Veteran's own genetic makeup. He noted that the degenerative disc disease certainly may have worsened in the years since the Veteran's service, but that he does not believe it is causally related to his service. He also stated his opinion that the herniation and radiculopathy first noted in 2003 was unrelated to service and unrelated to his degenerative disc disease, which had been present prior to 2003. He explained that the physician's note in 2003 that degenerative disc disease had been present previously was simply acknowledging that degenerative disc disease is not a disability that occurs immediately. He summarized his opinion by stating that there was no compelling evidence that the Veteran had a back injury or back problems during or immediately upon discharge from service. He further stated that the Veteran has degenerative disc disease that has likely been progressive for about the last ten years, but he did not have any inciting or aggravating event and that he suffered a herniated disc with increased radiculopathy in 2003 when he experienced an inciting event. The Board places substantial weight on this probative opinion. The opinion addresses the pertinent question at hand, describes the disability in sufficient detail, and thoroughly explains the reasoning for the conclusions reached, thus, allowing the Board to make a fully informed evaluation of the underlying medical issues. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (providing that a medical opinion must support its conclusion with an analysis that the Board can consider and weigh against any contrary opinions). Further, the opinion reflects that pertinent evidence, including post-service treatment records and lay statements of record, was considered in reaching the medical conclusions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (holding that it is the reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion). Subsequent to the February 2013 IME opinion, the Veteran submitted September 1994 through October 2003 private medical records from Regional West Physicians Clinic reflecting continuing treatment for low back pain and strain and treatment regarding his 2003 work-related injury. Although the February 2013 IME did not have the opportunity to consider these records, the Board does not find that it is necessary to provide them to the physician for further review and an addendum opinion, as they only provide supporting evidence for a factor that the physician already took into consideration. Specifically, they show evidence of a continuity of symptomatology of back pain since as early as September 1994. As explained above, the IME considered the lay statements regarding the Veteran's continuity of symptomatology of back pain when formulating his opinion. The additional medical records do not show that any inciting event occurred during service other than what the IME considered, that is, the effect of the Veteran's in-service work duties. Therefore, these records do not provide evidence that contradicts the February 2013 IME opinion or that raises questions about the conclusions reached therein. The Board has also considered whether presumptive service connection for arthritis as a chronic disease is warranted in the instant case. Although the Veteran has indicated that he experienced symptoms of pain in his back during service and after his service discharge, the evidence of record fails to establish that he had arthritis to a compensable level within one year of his separation from service. Private treatment records show treatment for low back pain in September 1994, which is more than one year after the Veteran's service discharge; arthritis was not diagnosed at that time. Hence, the criteria for presumptive service connection for the low back disability as a chronic disease have not been satisfied. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Furthermore, although the record contains lay and medical evidence reflecting continuity of symptomatology of low back pain since service, there was no condition noted in service that was indicative of a chronic back disability; thus, it is not necessary to further address the evidence regarding continuity of symptomatology. 38 C.F.R. § 3.303(b); see Walker, 708 F.3d at 1339. Notably, even if there was a condition noted in service that was indicative of a chronic back disability, medical expertise would be required to relate the Veteran's present arthritis etiologically to his post-service symptoms, since this determination is not one that is capable of observation by a lay person. See Savage v. Gober, 10 Vet. App. 488, 497-98 (1997); Walker, 708 F.3d at 1336, 1340 n.5. As explained above, the probative medical evidence of record clearly reaches the conclusion that the Veteran's current low back disability is unrelated to anything that occurred during service, even when considering the Veteran's continuity of symptomatology of back pain. There is no other evidence in the record indicating a relationship between the Veteran's service and his current low back disability. Hence, a preponderance of the evidence is against these theories of entitlement. Service Connection on a Secondary Basis The Veteran also contends that his low back disability is secondary to his service-connected left ankle injury residuals. Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Under 38 C.F.R. § 3.310, secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a nonservice-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. Part 4) 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). As explained above, the evidence clearly shows the Veteran has a current diagnosis of a low back disability. Additionally, an August 2009 rating decision granted service connection for residuals of a left ankle injury. Hence, the first two elements of the claim for secondary service connection have been established. The key inquiry in this case is whether these service-connected disabilities caused or aggravated the Veteran's low back disability. In June 2011, the Veteran was given a VA examination evaluating whether his service-connected left ankle injury residuals caused or aggravated his low back disability. The Veteran told the examiner that he did not seek routine medical care between 1993 and 2001. He indicated that his back pain began around 1991 and seemed to progress a bit through the years. The examiner noted that the Veteran's entrance and separation examinations were negative for low back-related complaints and that his first major muscle spasm for which he sought treatment occurred in 2003. She also discussed in detail the Veteran's history of low back treatment, which included MRIs in 2003, 2005, and 2009, and repeated epidural injections. She noted the Veteran's reports that his left ankle continued to go out on him if he was not walking on level ground or stepped awkwardly on a rock. He explained that his ankle would roll inward and he would experience swelling around the bone on the outer aspect of his ankle after a sprain. He reported experiencing sprains approximately ten times in the last several years, with the most recent sprain occurring in February 2011. Physical examination revealed the Veteran ambulated unassisted without antalgia. The examiner noted his gait was steady with normal pace and there was no abnormal shoe wear pattern. In reviewing the Veteran's history and examination results, the examiner opined that the low back disability was less likely than not caused, related to, or aggravated by service-connected left ankle injury residuals. She indicated that she did not believe the Veteran's left ankle sprains were the precipitating factors of right sciatic flare-ups or episodes of low back pain. She noted that the Veteran's reported symptoms of continued left ankle flare-ups were not causally associated with episodes of back pain and that physical examination did not reveal any limp or gait abnormalities due to the left ankle. She did not find any indication in the records of a causative relationship between the left ankle and low back disability. She also was unaware of any medical literature that causally associates residuals of ankle sprains to degenerative disc disease. She ultimately noted that the Veteran was not receiving any ongoing treatment for the left ankle and that history and examination did not show evidence of sufficient pathology of the left ankle such that it would cause or aggravate any lumbar conditions. The Board places substantial weight on this probative opinion. The examination report reflects that the examiner thoroughly reviewed the claims file, completed a physical examination of both the left ankle and the back, reviewed medical literature, and provided a thorough rationale regarding whether the service-connected residuals of left ankle sprains caused or aggravated the Veteran's low back disability. See Stefl, 21 Vet. App. at 124. The only evidence of record that supports the Veteran's claim is lay statements regarding the Veteran's altered gait. Specifically, in a May 2011 submission, the Veteran's representative reported that the Veteran had indicated he needed to alter his gait to accommodate the on-going pain due to the injury to his ankle. The Veteran used an ankle brace when possible, but his ankle injury residuals still caused him to adjust his walking manner, which he alleged resulted in aggravating his back disability. In a statement submitted in August 2011, the Veteran indicated that his wife noticed that he had gait problems right after they were married and that every time his ankle went out, he wrenched his back from catching himself from falling. He also stated that in service he had a cast on his ankle when he was still working aboard a ship, which made it more difficult for him to climb the steep ladders. The Veteran is competent to provide evidence regarding his observable symptoms and the Board finds his statements to be credible. However, the Board places greater weight of probative value on the June 2011 VA examiner's report. Although the August 2011 statement was submitted subsequent to the June 2011 examination, the examiner took into consideration similar statements regarding his altered gait that were already of record, including what the Veteran reported at the June 2011 examination, but still reached the conclusion that the service-connected left ankle condition did not cause or aggravate his low back disability. See Roberson v. Shinseki, 22 Vet. App. 358, 365 (2009) ("A medical examiner need not discuss all evidence favorable to an appellant's claim when rendering an opinion."). The Board concludes that a preponderance of the evidence is against a finding that the Veteran's low back disability was caused or aggravated by service-connected residuals of a left ankle injury. In summary, the claim of service connection for a low back disability is denied based on consideration of direct, presumptive, and secondary service connection theories of entitlement. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran's claim for service connection for a low back disability, the benefit-of-the-doubt rule is not for application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for a low back disability is denied. ____________________________________________ Laura H. Eskenazi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs