Citation Nr: 1326177 Decision Date: 08/16/13 Archive Date: 08/26/13 DOCKET NO. 05-00 957 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for arthritis of the right elbow, to include as due to Agent Orange exposure. 3. Entitlement to service connection for arthritis of the left elbow, to include as due to Agent Orange exposure. 4. Entitlement to service connection for arthritis of right hip, to include as due to Agent Orange exposure. 5. Entitlement to service connection for arthritis of left hip, to include as due to Agent Orange exposure. 6. Entitlement to service connection for arthritis of right shoulder, to include as due to Agent Orange exposure. 7. Entitlement to service connection for arthritis of left shoulder, to include as due to Agent Orange exposure. 8. Entitlement to service connection for arthritis of right wrist, to include as due to Agent Orange exposure. 9. Entitlement to service connection for arthritis of left wrist, to include as due to Agent Orange exposure. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. J. Vecchiollo INTRODUCTION The Veteran had active service from November 1965 to October 1969, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2004 RO rating decision that determined that new and material evidence had not been received to reopen a claim for entitlement to service connection for postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer (claimed as a bleeding ulcer). By this decision, the RO also denied service connection for tinnitus and for arthritis of multiple joints. In November 2007, the Board remanded the issue of whether new and material evidence has been received to reopen a claim for entitlement to service connection for postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer, as well as the issues of entitlement to service connection for tinnitus and for arthritis of multiple joints, to include as due to Agent Orange exposure, for further development. In April 2011, the Board reopened and remanded the issue of entitlement to service connection for postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer; granted service connection for bilateral hearing loss; and remanded the issues of entitlement to service connection for tinnitus and for arthritis of multiple joints, to include as due to Agent Orange exposure, for further development. A January 2013 Board decision granted service connection for postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer, and again remanded the issues of entitlement to service connection for tinnitus and for arthritis of multiple joints, to include as due to Agent Orange exposure, for further development. In a May 2013 supplemental statement of the case, the AMC divided the issue of entitlement to service connection for arthritis of multiple joints into eight separate issue as set forth in the front page of this decision. An Appeals Management Center (AMC) note dated in May 2013 notified the RO that the Veteran's claims file contained inferred/non-AMC issues, i.e., service connection for sarcoidosis (which was previously denied in a July 2005 rating decision) and that the Veteran has met the schedular requirement for a total disability rating due to individual unemployability (TDIU). FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran's tinnitus was not present in service or until many years thereafter and is not related to service or to an incident of service origin, including in-service acoustic trauma. 2. The preponderance of the evidence shows that the Veteran does not have a current chronic disability of either elbow. 3. The preponderance of the evidence shows that the Veteran's current disability of the bilateral hips, shoulders, and wrists, were not present in service or until many years thereafter and are not related to service or to an incident of service origin, including his in-service exposure to Agent Orange. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for tinnitus have not been met. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria for entitlement to service connection for arthritis of the right elbow have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 3. The criteria for entitlement to service connection for arthritis of the left elbow have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 4. The criteria for entitlement to service connection for arthritis of the right hip have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 5. The criteria for entitlement to service connection for arthritis of the left hip have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 6. The criteria for entitlement to service connection for arthritis of the right shoulder have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 7. The criteria for entitlement to service connection for arthritis of the left shoulder have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 8. The criteria for entitlement to service connection for arthritis of the right wrist have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 9. The criteria for entitlement to service connection for arthritis of the left wrist have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The 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 v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The RO provided the appellant with notice in November 2007, subsequent to the initial adjudication. While the notice was not provided prior to the initial adjudication, the claimant has had the opportunity to submit additional argument and evidence, and to meaningfully participate in the adjudication process. The claim was subsequently readjudicated in a February 2009 supplemental statement of the case, following the provision of notice. The appellant has not alleged any prejudice as a result of the untimely notification, nor has any been shown. The notification substantially complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) identifying the five elements of a service connection claim; Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. VA has obtained service treatment records, assisted the appellant in obtaining evidence, afforded the appellant physical examinations, obtained medical opinions as to the etiology and severity of disabilities, and afforded the appellant the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. This case was previously before the Board in November 2007, April 2011, and January 2013. At these times, the Board remanded the Veteran's claim for additional treatment and Social Security Administration (SSA) records, as well as adequate examinations. The Board acknowledges that it has a duty to ensure compliance with its remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). Additional treatment record, SSA records and adequate examinations were obtained. VA is required to make reasonable efforts to assist a claimant in obtaining evidence to substantiate his claim for benefits so long as he "adequately identifies those records and authorizes the Secretary to obtain them," the veteran has the ultimate responsibility to locate and secure the records, and VA is under no duty to obtain records for which the veteran has not provided an authorization as he cannot remain in a passive role. See Hyatt v. Nicholson, 21 Vet. App. 390, 394-95 (2007); Loving v. Nicholson, 19 Vet. App. 96, 102 (2005). In this regard, the Veteran was requested, in an AMC letter dated in May 2011, pursuant to April 2011 Board remand, to provide authorization to enable the VA to obtain occupational records, including audiological evaluations, from a past employer. The Veteran did not return the authorization form. The Board does find substantial compliance with its remand instructions and determines that the case may move forward without prejudice to the Veteran. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial compliance with the terms of the Board's remand would be required, not strict compliance). VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. II. Analysis Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). In addition, arthritis will be presumed to have been incurred in or aggravated by service if it had become manifest to a degree of 10 percent or more within one year of a veteran's separation from service. 38 U.S.C.A. §§ 1101 , 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307 , 3.309. Thus, service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Other diseases initially diagnosed after service also may be service connected if the evidence, including that pertinent to service, shows the diseases were incurred in service. 38 C.F.R. § 3.303(d). To establish a showing of chronic disease in service, or within a presumptive period per § 3.307, a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic," is required. 38 C.F.R. § 3.303(b). Subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Id. The Veteran contends that his arthritis of multiple joints may have resulted from Agent Orange exposure during his Vietnam service. Under 38 U.S.C.A. § 1116(a)(2) and 38 C.F.R. § 3.309(e), as to Veterans who served in Vietnam during a certain time period, selected diseases may be presumed to have resulted from exposure to herbicide agents such as Agent Orange. According to the Veteran's service records, he served in the Republic of Vietnam during the Vietnam Era, therefore, his exposure to toxic herbicides is presumed. See 38 U.S.C.A. §§ 1116, 1154. The Secretary of the Department of Veterans Affairs has decided that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. The Board notes that joint arthritis is not a disease listed in 38 C.F.R. § 3.309(e). The availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a Veteran from establishing service connection with proof of direct causation. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In cases where a Veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C.A. § 1154(b) (West 2002) and its implementing regulation, 38 C.F.R. § 3.304(d) (2012), are applicable. This statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence. If the Veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that in the case of a combat Veteran not only is the combat injury presumed, but so is the disability due to the in-service combat injury. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). In this regard, the Board accepts that the Veteran was exposed to loud noises as a result of combat. To establish service connection, however, there must be the evidence of a current disability and a causal relationship between the current disability and the combat injury. Id. (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Tinnitus The Veteran has stated that he has continuously had tinnitus since service due to in-service noise exposure, including being attacked in Vietnam by mortar fire and other bombs. In July 2013 written argument, the Veteran's representative noted that there is a VA Adjudication Procedure Manual (Manual) provision that states that if hearing loss is service connected, and tinnitus is a symptom of hearing loss, VA will concede that the hearing loss and tinnitus result from the same etiology. See M21-1MR, Part III, Subpart iv, Chapter 4, Section B, Paragraph 12(f). The Veteran's service treatment records are negative for any findings, complaints or treatment of tinnitus. A VA treatment note dated in February 2004, noted that ear examination was negative for hearing loss and tinnitus. A VA audiological consultation was conducted in January 2008. The Veteran complained of hearing loss of 10 years duration. He did not mention tinnitus. The diagnosis was sensorineural hearing loss. The examiner of the January 2009 VA audiological examination stated that there was no complaint of tinnitus. A VA examination was conducted in August 2011. The Veteran informed the examiner that his tinnitus began "a couple of years ago." The examiner noted that the Veteran did not report tinnitus during the January 2009 examination. The examiner opined that it was less likely as not that such "late-onset" tinnitus would be related to service. According to the National Academy of Sciences (NAS), Institutes of Medicine (IOM), the examiner explained, as the interval between the noise exposure and the onset of tinnitus increases, the probability that the tinnitus is due that that noise exposure decreases. A VA audiological examination was conducted in March 2013. The examiner noted that the Veteran served in the Marine Corps from 1965 to1969, and he reported that his military occupational specialty (MOS) was aircraft mechanic. The Veteran reported a history of military noise exposure from jet aircraft, bombs, and gunfire (he reported using hearing protection). The Veteran has a 20-year history of occupational noise exposure while working in law enforcement where he had to annually qualify on the firing range (with hearing protection). The Veteran denied recreational noise exposure. The Veteran noted a history of a head injury with loss of consciousness while in Vietnam. His otologic history is also significant for a left tympanic membrane perforation in 1963. After a review of the records, the examiner noted a statement written by the Veteran in which he indicated that the tinnitus had been present since he was in the service and was due to his service-connected hearing loss. The examiner also noted that tinnitus was first documented at the in the August 2011 VA examination. At that examination, the Veteran had reported that the onset of tinnitus was "a couple of years ago" and the 2011 VA examiner opined that tinnitus was less likely than not a result of service. The March 2013 examiner also noted that the presence of tinnitus was not reported at the January 2009 VA examination nor was it documented as being present at the January 2008 VA audiological evaluation. The examiner further opined that according to IOM there is no scientific evidence to support delayed-onset tinnitus due to noise exposure. Therefore, based on this rationale and because the Veteran has consistently not provided a clear nexus between the onset of tinnitus and his military service; tinnitus is deemed less likely than not caused by or a result of military noise exposure. In regards to whether or not the tinnitus was caused by the Veteran's service connected hearing loss, the examiner noted that hearing loss does not cause tinnitus. Hearing loss and tinnitus often co-exist and may have similar etiologies (i.e. noise exposure), however, hearing loss does not cause tinnitus and the two conditions can exist independently of one another. Upon careful review of the record, the Board finds that service connection for tinnitus is not warranted. Service connection may be granted when all the evidence establishes a nexus between service and current complaints. Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). The Board observes that the Veteran is diagnosed as having tinnitus. Thus, the question is not if whether at any time since his claim for service connection there has existed a current disability. Rather, the question involves the onset and etiology of this disability. In this case, there is no probative evidence establishing a medical nexus between military service and the Veteran's tinnitus disorder. Rather, the evidence of record weighs against such a finding. In this case, the Board finds that the medical opinions are competent and highly probative. The August 2011 and March 2013 VA examiners opined that the Veteran's tinnitus was not caused by or a result of military noise exposure. In addition, March 2013 VA examiner opined that the Veteran reported the onset of tinnitus decades after separation and that there was evidence that the Veteran's tinnitus disorder was not attributable to in-service noise exposure. In addition, the March 2013 VA examiner found that tinnitus was not caused by the Veteran's service-connected hearing loss. The VA examiners based their opinions on a review of the Veteran's medical records, his lay report of the onset of his disability, the results of objective testing during VA examinations, and their specialized training, and concluded that the Veteran's tinnitus was less likely than not related to service. As such, the competent medical evidence of record does not support the assertion that his tinnitus disorder is related to his active service. The Veteran is not a licensed health care professional; therefore, the lay evidence offered by the Veteran is not competent medical evidence and does not establish a relationship between his tinnitus and exposure to loud noise during service. The Board acknowledges, however, that the Veteran has submitted written statements indicating that he has had tinnitus due to noise exposure since service. The Veteran is competent to report the observable manifestations of a disability even though the medical evidence does not show a report of recurrent symptoms since service. Although at times, the Veteran has reported that his tinnitus began in service; he also told a VA examiner in August 2011 that his tinnitus began a few years ago. In addition, he did not report tinnitus at VA examinations in 2008 and 2009. The Board finds the statements to medical personnel in the 2000's essentially indicating that his tinnitus began many years after service to be more credible. See Curry v. Brown, 7 Vet. App. 59 (1994) (one is usually more truthful when providing information for receiving medical treatment than when one is providing information for receiving monetary compensation); see also Charles v. Principi, 16 Vet. App. 370, 374-75 (2002) (a veteran is competent to testify as to the presence of tinnitus); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Board notes that M21-1MR, Part III, Subpart iv, Chapter 4, Section B, Paragraph 12(f) indicates if the examiner states tinnitus is a symptom of hearing loss, establish service connection for tinnitus on a direct, not secondary, basis. If the hearing loss is service connected, and the tinnitus is a symptom of the hearing loss, VA concedes that the hearing loss and tinnitus result from the same etiology. Therefore, service connection is warranted for tinnitus on a direct basis in these cases. Paragraph 12(f) also indicates if the examiner states tinnitus is not related to hearing loss, determine, based on all the evidence of record, whether or not the etiology of tinnitus requires further assessment by one of more additional examinations. Paragraph 12(f) also provides an example: if the Veteran claims tinnitus due to hearing loss, and the examiner says they are not related, no further action is needed. In this case, the March 2013 VA examiner opined that the Veteran's tinnitus was not a symptom his service-connected hearing loss, therefore, service connection for tinnitus is not warranted pursuant to this Manual provision. As such, the weight of the credible evidence shows that the Veteran's tinnitus first manifested many years after service is not related to service or any incident therein. As the preponderance of the evidence is against the Veteran's claims for service connection for tinnitus, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Multiple Joint Arthritis The Veteran's service treatment records are silent for a disability of the elbows, hips, shoulders, and wrists. A VA treatment note dated in February 2004, noted that the Veteran was undergoing narcotic pain management, complained of muscle stiffness and joint pain, and upper and lower extremities examination were normal. A VA treatment note dated in March 2006 noted that the Veteran complained of diffuse joint pain. The diagnoses were neck pain, low back pain, osteoarthritis of the knees, and sarcoidosis. In January 2007, the Veteran presented with complaints of multiple joint pains for many years. A January 2007 VA rheumatology consultation noted that the Veteran presented with a 60-pound weight loss and severe fatigue and malaise, and was diagnosed with sarcoidosis three years ago. The diagnoses were polyarthralgias, most likely multifactorial, with osteoarthritis and fibromyalgia; and history of biopsy-proven sarcoid not causing joint pain, should be steroid responsive. Subsequent treatment records note continued narcotic pain medication and corticosteroids were prescribed to treat these conditions. A VA joints examination was conducted in January 2009. The Veteran stated he has had arthritis since service. As pertinent here, the examiner diagnosed fibromyalgia; osteoarthritis of bilateral wrists, shoulders, and knees; and bilateral hip strain. The examiner noted that the Veteran had a normal physical examination on discharge in December 1968. There were no complaints of or treatment of the hips, wrists or shoulders in service. The Veteran sustained a post-service injury to the right wrist subsequent to service in 1982. And there were no further complaints of multiple joint pain until 2007. The examiner opined that it is less likely as not that the Veteran's disabilities are related to service. The examiner opined that the Veteran's wrist and shoulder arthritis is more likely related to aging. The examiner cited to a national study noting that the prevalence of osteoarthritis in individuals over age 55 is over 80 percent. Subsequent records note the Veteran was participating in aquatic therapy and a home program of exercise. In July 2009, the Veteran complained of bilateral hip pain. A VA joints examination was conducted in August 2011 in which the examiner stated that the opinion was unchanged from the January 2009 opinion. In March 2013, the Veteran was still being provided aquatic therapy. A VA examination was conducted in April 2013. The examiner noted that the Veteran manifested bilateral elbow pain but that the elbow examination was normal. The examiner diagnosed mild arthritis of the bilateral hips and shoulders, and degenerative joint disease (DJD) of the bilateral wrists. The examiner again stated that the opinion was unchanged from the January 2009 opinion in that the aforementioned multiple-joint arthritis was less likely as not incurred in service. The examiner did add that the medical literature does not support the proposition that Agent Orange exposure causes arthritis. Regarding the Veteran's bilateral elbow claim, in the absence of proof of a present disability, there can be no valid claim for service connection; an appellant's belief that he or she is entitled to some sort of benefit simply because he or she had a disease or injury while on active service is mistaken, as Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board notes the Veteran's claim on bilateral elbow pain. However, pain is not analogous with disability. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), vacated in part, appeal dismissed in part sub nom., Sanchez- Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001) (dismissing challenge to the issue whether pain, alone, can be considered a disability). The treatment records are silent as to any elbow disability and no VA compensation examination has diagnosed an elbow disability. In fact, the April 2013 bilateral elbow examination was normal. As such, the Board finds that a preponderance of the evidence is against the claim for service connection for bilateral elbow disabilities. As the preponderance of the evidence is against the claim of service connection for bilateral elbow disabilities, the benefit of the doubt rule is not applicable, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board finds that the Veteran's arthritis of the bilateral hips, shoulders, and wrists did not manifest during service, within one year of separation from service, and is not causally or etiologically related to service, including Agent Orange exposure. The most persuasive evidence in this case is the opinion provided by a VA compensation examination report of January 2009, August 2011, and April 2013. They were based on the claims folder review, interview with the Veteran, and an examination of the Veteran. The VA examiners fully considered the evidence of record, the Veteran's complaints and his reported history Otherwise, the only evidence relating the Veteran's bilateral hip, shoulder, and wrist disabilities to his service are the Veteran's lay assertions that the disabilities are causally related to service. Again, the Board notes that he has not demonstrated that he has expertise in medical matters. While there is no bright line exclusionary rule that a lay person cannot provide opinion evidence as to a nexus between an in-service event and a current condition, not all medical questions lend themselves to lay opinion evidence. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In Davidson, the United States Court of Appeals for the Federal Circuit (Federal Circuit) referred to Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) for guidance. In footnote 4 of Jandreau, the Federal Circuit indicated that the complexity of the claimed disability is to be considered in determining whether lay evidence is competent. As to a nexus opinion relating any current disability to his active service, the Board finds that the etiology of the Veteran's joint disabilities is too complex an issue, one typically determined by persons with medical training, to lend itself to lay opinion evidence. The Veteran is certainly competent to testify as to symptoms such as joint pain, which are non-medical in nature; however he is not competent to render a medical diagnosis or etiology. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology that is not medical in nature); see also, Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (certain disabilities are not conditions capable of lay diagnosis). No medical evidence of record finds a relation between active duty service and the Veteran's arthritis of the bilateral hips, shoulders, and wrist. The only medical opinion in the file was provided by the VA examiners in January 2009, August 2011, and April 2013. The examiners were well-informed and opined that it is not at least as likely as not that the Veteran's arthritis of bilateral hips, shoulders, and wrists are due to military service. There is no contrary medical opinion of record. In sum, the evidence does not show that the Veteran's arthritis of the bilateral hips, shoulders, and wrists is related to service. Accordingly, the preponderance of the evidence is against the claims, and service connection for arthritis of the bilateral hips, shoulders, and wrists is denied. ORDER Service connection for tinnitus is denied. Service connection for arthritis of the right elbow is denied. Service connection for arthritis of the left elbow is denied. Service connection for arthritis of the right hip is denied. Service connection for arthritis of the left hip is denied. Service connection for arthritis of the right shoulder is denied. Service connection for arthritis of the left shoulder is denied. Service connection for arthritis of the right wrist is denied. Service connection for arthritis of the left wrist is denied. ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs