Citation Nr: 1326768 Decision Date: 08/21/13 Archive Date: 08/29/13 DOCKET NO. 05-25 574 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a right shoulder disorder. 2. Entitlement to service connection for a left hand disorder. 3. Entitlement to service connection for a bilateral wrist disorder. 4. Entitlement to service connection for a bilateral knee disorder. 5. Entitlement to service connection for a bilateral hip disorder. REPRESENTATION Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Shauna M. Watkins, Associate Counsel INTRODUCTION The Veteran had active military service from September 1963 to July 1967. These claims come before the Board of Veterans' Appeals (Board) on appeal of March 2004 and July 2006 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. Specifically, the March 2004 rating decision denied service connection for right shoulder, left hand, bilateral knee, and bilateral hip disorders and the July 2006 rating decision denied service connection for bilateral wrist disorders. In a VA Form 9 (Appeal to Board of Veterans' Appeals) and in written statements received at the RO in August 2005, August 2006, August 2007 and June 2008, the Veteran requested hearings before a Decision Review Officer (DRO) and the Board. However, in a written statement received in September 2008, the Veteran indicated that he no longer wanted a hearing. The Board thus deems the DRO and Board hearing requests withdrawn, the latter pursuant to 38 C.F.R. § 20.702(d) (2012). The Veteran's claims were previously remanded by the Board for further development in January 2010, March 2012, and April 2013 for further evidentiary development. The Board's prior remand directives and the subsequent actions by the RO and VA Appeals Management Center (AMC) will be further discussed below. The Veteran's claims have been returned to the Board for appellate proceedings. The Veteran's Virtual VA paperless claims file has been reviewed in preparing this decision, along with his paper claims file. FINDINGS OF FACT 1. The Veteran's right shoulder disorder, to include degenerative joint disease, was not manifested during his active military service, is not shown to be causally or etiologically related to his active military service, and is not shown to have manifested to a degree of 10 percent or more within one year from the date of separation from the military. 2. The Veteran's left hand disorder, to include degenerative joint disease, was not manifested during his active military service, is not shown to be causally or etiologically related to his active military service, and is not shown to have manifested to a degree of 10 percent or more within one year from the date of separation from the military. 3. The Veteran's bilateral wrist disorders, to include degenerative joint disease, were not manifested during his active military service, are not shown to be causally or etiologically related to his active military service, and are not shown to have manifested to a degree of 10 percent or more within one year from the date of separation from the military. 4. The Veteran's bilateral knee disorders, to include degenerative joint disease, were not manifested during his active military service, are not shown to be causally or etiologically related to his active military service, and are not shown to have manifested to a degree of 10 percent or more within one year from the date of separation from the military. 5. The Veteran's bilateral hip disorders are not shown to be causally or etiologically related to his active military service. CONCLUSIONS OF LAW 1. Service connection for a right shoulder disorder, to include degenerative joint disease, is not established. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. Service connection for a left hand disorder, to include degenerative joint disease, is not established. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 3. Service connection for a bilateral wrist disorder, to include degenerative joint disease, is not established. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 4. Service connection for a bilateral knee disorder, to include degenerative joint disease, is not established. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 5. Service connection for a bilateral hip disorder is not established. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Legal Criteria To establish direct service connection, the record must contain: (1) medical evidence of a current disorder; (2) medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease; and, (3) medical evidence of a nexus between the current disorder and the in-service disease or injury. In other words, entitlement to service connection for a particular disorder requires evidence of the existence of a current disorder and evidence that the disorder resulted from a disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis (i.e., degenerative joint disease), will be presumed if they manifest to a compensable degree within one year following the active military service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). Regarding the degenerative joint disease diagnoses, for the showing of a chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a) (West 2002); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); see 38 C.F.R. §§ 3.102. If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. II. Analysis The Veteran seeks service connection for right shoulder, left hand, bilateral wrist, bilateral knee, and bilateral hip disorders. He filed a claim for service connection for the right shoulder, left hand, bilateral knees, and bilateral hips in December 2002 and filed a claim for service connection for bilateral wrist disorders in April 2005. With regard to all of the issues on appeal, the Veteran was provided a VA examination in connection with his claimed disorders in December 2005. Significantly, this examiner found that the Veteran had "multiple site arthralgia, which is due to periarticular and para-articular soft tissue inflammation and pain, including multiple sites of tendonitis and myositis." The examiner generally stated: [M]y review of his records and my examination led me to a rather firm opinion which must include speculation because documentation is hard to come by. However, I think it is far more likely than not that that this [V]eteran's problems started and were recorded to have been present while he was on active duty, then continued to the present time, and now he is approaching complete disability. See the December 2005 VA examination report. In January 2010, the Board noted the contradictory medical evidence, recounted above. At that time, the Board noted the possibility, as stated by the December 2005 VA examiner, that the Veteran's reports of pain throughout his body may be indicative of "widespread multi-site arthralgia," and concluded that further VA examinations were necessary to determine the nature and etiologies of his alleged disorders. The Board noted that the Veteran was already service connected for arthritis of the spine and right hand, and thus, it was unclear from the opinion as to which joints the examiner was referring to; service-connected joints or non-service-connected joints. Accordingly, the Board directed the RO to return the claims file to the examiner who conducted the December 2005 VA examination for clarification regarding which of the claimed joints were affected by the widespread arthralgia and which were affected by arthritis, confirmed on X-rays, or other medical disorders, and for an opinion addressing the etiology of all claimed joint disorders shown to exist. The Board advised the RO to transfer the claims file to a different examiner for a new VA examination if the December 2005 examiner was not available. The RO transferred the Veteran's claims file to a new VA examiner for an opinion addressing the aforementioned matters, not an examination, as instructed. Pursuant to the January 2010 Board remand, an opinion was obtained in June 2010. Significantly, the June 2010 VA examiner wrote that "[a]ny arthritis appears to be related to wear and tear of the aging process." Therefore, the examiner determined that it was less likely than not that the Veteran's arthritis (no joints specified) was related to his active military service. The Board, in its March 2012 remand, pointed out that the June 2010 VA examiner discussed some, but not all, of the disorders at issue in this case, did not address which joints were affected by the widespread arthralgia, did not address many pertinent medical findings of record (the June 2010 VA examiner appears to have reviewed the service treatment records (STRs) and December 2005 VA examination report only), and did not provide rationale in ruling out a relationship between the disorders he discussed and the Veteran's service. Accordingly, the Board found this VA medical opinion to be inadequate, and remanded the claim for another VA examination and medical opinion. Such an opinion was obtained in April 2012. In its April 2013 remand, the Board found that the April 2012 VA examiner limited the inquiries regarding the joints to whether or not degenerative joint disease was present, and the Veteran's prior diagnoses that did not include degenerative joint disease were neither confirmed nor ruled out, and the opinions rendered by the April 2012 VA examiner did not address the etiology of these previously-diagnosed disorders. As such, the Board found that it was unclear whether these disorders have resolved or were, in the opinion of the April 2012 VA examiner, previously misdiagnosed. Also, the Board noted that the April 2012 VA examination report contained inconsistent statements regarding the Veteran's medical history. As such, the Board requested yet another VA examination and opinion. Such opinion was obtained in June 2013. A. Right Shoulder Disorder With regard to the right shoulder disorder, as noted above, the first element of service connection requires medical evidence of a current disorder. Here, a current diagnosis has been established. A December 2005 VA examination report reflects a diagnosis of right shoulder impingement syndrome. At the April 2012 VA examination, the Veteran was diagnosed with right shoulder sprain and arthritis. On VA examination in June 2013, the Veteran was diagnosed with acromioclavicular (AC) joint degeneration and impingement syndrome of the right shoulder. Thus, the Veteran has satisfied the first element of service connection. As stated above, the second element of service connection requires medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease. Here, while the Veteran's STRs document complaints of and treatment for painful arc syndrome and supraspinitis tendonitis of the left shoulder between July 1964 and September 1964, an August 1964 X-ray report also reflects that the Veteran complained of right shoulder pain upon elevation of his arms. X-rays taken of the right shoulder in service were normal and did not reveal arthritis of the right shoulder. There are no further complaints of or treatment for his right shoulder in the STRs. At his July 1967 separation examination, his right shoulder was normal. His active military service ended in July 1967. Post-service, in a July 1967 report of medical history completed in connection with employment, shortly after the Veteran's separation from the active military service, the Veteran specifically denied experiencing pain or arthritis in any of his joints, to include his right shoulder. The first post-service relevant complaint of right shoulder pain was in a November 1967 private employment medical record, in which the Veteran reported that his right shoulder was sore when he woke up that morning. He reported no history of injury at that time, and no diagnosis was provided. Again, the Veteran's active duty ended in July 1967. At a May 1970 private treatment visit, the Veteran reported that his right shoulder pain had worsened, noting that he bumped his right shoulder on a "jig" two days prior. The Veteran reported having a problem with his right shoulder five or six years prior and he stated that bumping the shoulder aggravated the old military injury. Private treatment records from Dr. W.N.G. reflect a diagnosis of bursitis of the right shoulder in December 1995. Private X-rays taken on the right shoulder in December 2005 were normal. Private treatment records from Dr. M.R.Z. reflect that, in December 1995, the Veteran reported right shoulder pain since his service in the Republic of Vietnam, and he was diagnosed with right shoulder impingement syndrome in February 1996. The Veteran was provided a VA examination in connection with his claim in July 2003, and X-ray testing at that time showed degenerative changes of the right shoulder indicative of impingement syndrome. Later that month, the Veteran underwent a private whole-body planar imaging test, which revealed "vague increased activity" in the right shoulder region, which was "consistent with degenerative change[s]." See a July 2003 whole-body planar imaging test. In January 2005, the Veteran submitted a written statement from Dr. R.M.C., asserting that he had treated the Veteran from 1967 to 1993 for multiple disorders, to include osteoarthritis of the right shoulder. However, the Veteran's claims file and Virtual VA file are devoid of reports of X-ray testing completed by Dr. R.M.C., which are consistent with this statement. A December 2005 VA examination report reflects a diagnosis of right shoulder impingement syndrome. As above, the examiner also found that the Veteran had "multiple site arthralgia, which is due to periarticular and para-articular soft tissue inflammation and pain, including multiple sites of tendonitis and myositis" and opined that this "multiple site arthralgia" began in service. In January 2010, the Board directed the RO to return the claims file to the examiner who conducted the December 2005 VA examination for clarification regarding which of the claimed joints were affected by the widespread arthralgia and which were affected by arthritis, confirmed on X-rays, or other medical disorders, and for an opinion addressing the etiology of all claimed joint disorders shown to exist. The opinion was obtained in June 2010. In the June 2010 VA opinion, the examiner reviewed the claims file, and noted that the Veteran was in a motor vehicle accident and was treated for his left shoulder during his active military service. The examiner stated that the Veteran's X-rays documented degenerative joint disease of the bilateral shoulders. The examiner stated that he could not determine if the degenerative joint disease of the shoulders were related to active military service, as the claims file did not contain any useful information regarding the shoulders. The examiner also pointed out that "[a]ny arthritis appears to be related to wear and tear of the aging process." Therefore, the examiner determined that it was less likely than not that the Veteran's arthritis (no joints specified) was related to his active military service. As above, in its March 2012 remand, the Board found this VA medical opinion to be inadequate, and remanded the claim for another VA examination and medical opinion. Upon remand, the Veteran was provided this VA examination in April 2012. Following a review of the claims file and a physical examination of the Veteran, the examiner determined that it is less likely as not that the Veteran's current right shoulder disorder is proximately due to or caused by his military service. The examiner reasoned that the Veteran's STRs contain documentation of several visits for a left shoulder problem, but no visits for a right shoulder problem. The examiner stated that both shoulders were X-rayed in service, and the X-rays were normal. In contrast, the examiner found that the current right shoulder X-rays, taken at the examination, showed AC joint arthritis. Thus, the examiner found that service connection for a right shoulder disorder has not been substantiated. As above, in its April 2013 remand, the Board found that the April 2012 VA examination report was inadequate. Significantly, the unfavorable nexus opinion concerning the Veteran's right shoulder was premised on a lack of in-service complaints of or treatment for a right shoulder disorder; however, as noted above, the Veteran reported pain in his right shoulder upon elevation of his right arm in August 1964. Accordingly, the Board remanded for a new VA examination to be obtained. Upon remand, the Veteran was afforded another VA examination and medical opinion in June 2013. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that the Veteran's current right shoulder disorder is less likely than not related to the acute disorder/treatment shown in the STRs and less likely than not related to his active military service. The examiner reasoned that there is evidence of complaints related to the right shoulder in the STRs in 1964, but X-rays of the right shoulder were negative. Following the 1964 in-service complaints, the examiner pointed out that there is no further evidence of care or treatment for the right shoulder in the STRs; however, the examiner pointed out that there are continued left shoulder complaints in the STRs. The examiner stated that the Veteran's military separation examination was negative for any right shoulder abnormalities or complaints on the medical self-assessment questionnaire. The examiner found that there was no interim data proximate to discharge, and that he could not establish chronicity for this disorder. In summary, the examiner provided a negative medical nexus opinion. As previously mentioned, the third element of service connection requires medical evidence of a nexus between the current disorder and the in-service disease or injury. Here, the claims file currently contains only negative medical nexus opinions pertaining to the right shoulder disorder. The Board notes that the Veteran reports continuous symptomatology of his right shoulder problems since his active military service. However, the Veteran's contentions are not supported by the medical evidence of record. Although the Veteran reported right shoulder pain in November 1967, shortly after his military discharge, the first post-service evidence of degenerative joint disease of the right shoulder is not dated until July 2003, thirty-six years after the Veteran's military separation in July 1967. Significantly, the record contains a post-service work injury in May 1970, in which the Veteran reported right shoulder pain. This post-service injury demonstrates that the Veteran has not had continuous right shoulder symptoms since his in-service injuries; instead, there are superseding causes. Further, the STRs do not show that the Veteran developed a chronic right shoulder disorder during his active military service. The STRs document right shoulder pain on only one occasion, which is not a chronic disorder. There is no evidence that the Veteran's right shoulder did not resolve prior to his military discharge, as there were no further complaints following the one instance of right shoulder pain in August 1964. At his July 1967 military separation examination, his right shoulder was found to be normal with no complaints of pain. When the Veteran was first treated post-service in November 1967, he did not indicate that his right shoulder pain had been present since his active military service, and in fact, denied any injury to the right shoulder and instead described a soreness that had started that morning, as opposed to a previous injury during his active military service. B. Left Hand Disorder With regard to the left hand disorder, as noted above, the first element of service connection requires medical evidence of a current disorder. Here, a current diagnosis has been established. At the April 2012 VA examination, the Veteran was diagnosed with arthritis of his left hand. On VA examination in June 2013, the Veteran was diagnosed with degenerative joint disease of the left hand. Thus, the Veteran has satisfied the first element of service connection. As stated above, the second element of service connection requires medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease. Here, a review of the Veteran's STRs reflects that he fractured the midportion of his fifth metacarpal and was treated with an ulnar nerve block at the elbow in March 1964. He continued to receive treatment for this injury until at least June 1964. Although the Veteran's STRs do not specify whether this injury affected the Veteran's left or right hand, the April 2012 VA examiner noted that the Veteran sustained such a fracture injury to his left hand during active duty. In contrast, the June 2013 VA examiner determined that it can be confidently deduced from the date that the in-service treatment is for the right hand. The examiner reasoned that there is documentation of a hand injury (fracture of the fifth metacarpal), but the side is not identified in the STR. However, the examiner indicated that the Veteran stated that he fractured his right fifth metacarpal while on active duty. The examiner also pointed out that the in-service X-ray slip noted X-rays of the right hand with a fracture of the fifth metacarpal. The examiner further stated that recent X-rays of the right hand also document an old healed fifth metacarpal fracture. The Veteran's STRs do not contain any further complaints of or treatment for the left hand. At his July 1967 separation examination, his left hand was normal. His active military service ended in July 1967. Post-service, in a July 1967 report of medical history completed in connection with employment, shortly after the Veteran's separation from the active military service, the Veteran specifically denied experiencing pain or arthritis in any of his joints. As above, the Veteran first filed a claim for service connection for a left hand disorder in December 2002. The first post-service medical evidence pertaining to the left hand was at a VA examination in June 2006, which, based on X-ray findings, documented degenerative changes in the left hand. As above, the Veteran's active duty ended in 1967. This lengthy period without treatment for the disorder weighs heavily against the claim. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (holding that service incurrence may be rebutted by the absence of medical treatment of the claimed disorder for many years after the military discharge). In January 2005, the Veteran submitted a written statement from Dr. R.M.C., asserting that he had treated the Veteran from 1967 to 1993 for multiple disorders, to include osteoarthritis of the left hand. See a January 2005 statement from Dr. R.M.C. However, the Veteran's claims file is devoid of reports of X-ray testing completed by Dr. R.M.C., which are consistent with this statement. As above, a December 2005 VA examiner found that the Veteran had "multiple site arthralgia, which is due to periarticular and para-articular soft tissue inflammation and pain, including multiple sites of tendonitis and myositis" and opined that this "multiple site arthralgia" began in service. In June 2006, the Veteran was afforded a VA wrists examination. Based on X-ray findings, the VA examiner determined that the Veteran had degenerative joint disease of his metacarpal joints of his left hand. At the examination, the Veteran reported heavy work with his hands, pulling on tow bars and moving planes, when he was onboard a ship during his active military service. The examiner stated that this type of work would put lots of wear on the metatcarpal joints of the hand. The Veteran was provided a VA examination of his hands in March 2007; however, no diagnosis or opinion was discussed with regard to the Veteran's left hand. A June 2008 VA general examination report reflects a diagnosis of severe degenerative change of the carpal and metacarpal joints of the left thumb. The June 2008 VA examiner did not render a nexus opinion regarding this diagnosis. In January 2010, the Board directed the RO to return the claims file to the examiner who conducted the December 2005 VA examination for clarification regarding which of the claimed joints were affected by the widespread arthralgia and which were affected by arthritis, confirmed on X-rays, or other medical disorders, and for an opinion addressing the etiology of all claimed joint disorders shown to exist. The opinion was obtained in June 2010. In the June 2010 VA opinion, the examiner reviewed the claims file, and noted that the Veteran was in a motor vehicle accident and was treated for his fifth MP (metacarpophalangeal) joint (hand not specified) during his active military service. The examiner pointed out that "[a]ny arthritis appears to be related to wear and tear of the aging process." Therefore, the examiner determined that it is less likely than not that the Veteran's arthritis (no joints specified) is related to his active military service. The Board, in its March 2012 remand, pointed out that the June 2010 VA examiner discussed some, but not all, of the disorders at issue in this case, did not address which joints were affected by the widespread arthralgia, did not address many pertinent medical findings of record (the June 2010 VA examiner appears to have reviewed the STRs and December 2005 VA examination report only), and did not provide rationale in ruling out a relationship between the disorders he discussed and the Veteran's service. Accordingly, the Board found this VA medical opinion to be inadequate, and remanded the claim for another VA examination and medical opinion. Upon remand, the Veteran was provided another VA examination in April 2012. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that it is less likely as not that the Veteran's current problems are proximately due to or caused by his active military service. The examiner reasoned that the Veteran's STRs contain no documentation of any left hand problems. The examiner stated that X-rays taken at the examination showed only degenerative joint disease bilaterally of the first metacarpal joints of the thumb. Thus, the examiner found that service connection for a left hand disorder is not substantiated. As above, in its April 2013 remand, the Board found that the April 2012 VA examination report was inadequate. Specifically, although the April 2012 examiner noted that the Veteran's STRs reflected an in-service left hand injury, the negative nexus opinion was premised on the lack of an in-service left hand injury. Accordingly, the Board remanded for a new VA examination to be obtained. Upon remand, the Veteran was afforded another VA examination and medical opinion in June 2013. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that the Veteran's current left hand/thumb disorder is not related to his active military service. The examiner reasoned that there is no evidence of any complaints of or treatment for a left hand disorder in the STRs. The examiner determined that it can be confidently deduced from the date that the in-service treatment is for the right hand. The examiner reasoned that there is documentation of a hand injury (fracture of the fifth metacarpal), but the side is not identified in the STR. However, the examiner indicated that the Veteran stated that he fractured his right fifth metacarpal while on active duty. The examiner also pointed out that the in-service X-ray slip noted X-rays of the right hand with a fracture of the fifth metacarpal. The examiner further stated that recent X-rays of the right hand also document an old healed fifth metacarpal fracture. The examiner also reasoned that there is no interim data proximate to discharge. The Veteran's military separation examination is negative for any left hand abnormalities, and no complaints related to the left hand were documented on the separation medical self-assessment questionnaire. Thus, the examiner provided a negative medical nexus opinion. As previously mentioned, the third element of service connection requires medical evidence of a nexus between the current disorder and the in-service disease or injury. Here, the claims file currently contains only negative medical nexus opinions pertaining to the left hand disorder. The Board notes that the Veteran reports continuous symptomatology of his left hand problems since his active military service. However, the Veteran's contentions are not supported by the medical evidence of record. Significantly, the STRs do show that the Veteran developed a chronic left hand disorder during his active service. Even giving the Veteran the benefit of the doubt that the STRs pertain to his left hand, and not his right hand as believed by the June 2013 VA examiner, the treatment only lasted from March 1964 until June 1964. From June 1964 to July 1967 (over three years), there are no further complaints of or treatment for his left hand in the STRs. There is no evidence in the STRs that the Veteran's left hand disorder did not resolve prior to his military discharge, as no abnormalities of the left hand were documented on his July 1967 military separation examination. Post-service, in a July 1967 report of medical completed in connection with employment, shortly after the Veteran's separation from active service, the Veteran specifically denied experiencing pain or arthritis in any of his joints. The first post-service complaint pertaining to the left hand is not until his June 2006 VA examination, which was scheduled for the purpose of establishing service connection for his left hand disorder. C. Bilateral Wrist Disorders With regard to the bilateral wrist disorders, as noted above, the first element of service connection requires medical evidence of a current disorder. Here, a current diagnosis has been established. At the April 2012 VA examination, the Veteran was diagnosed with arthritis and a sprain of the right and left wrist. On VA examination in June 2013 the Veteran was diagnosed with degenerative joint disease and carpel tunnel syndrome of the right and left wrist. Thus, the Veteran has satisfied the first element of service connection. As stated above, the second element of service connection requires medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease. Here, the Veteran's STRs are negative for any complaints of or treatment for the right or left wrist. However, the Board observes that the Veteran was involved in a motor vehicle accident in August 1966. While the treatment records surrounding this event focus on injuries to the Veteran's head and low back, the Board concedes that such an accident likely resulted in trauma, however slight, to the Veteran's wrists. At his July 1967 military separation examination, his upper extremities were normal. His active military service ended in July 1967. Post-service, in a July 1967 report of medical history completed in connection with employment, shortly after the Veteran's separation from the active military service, the Veteran specifically denied experiencing pain or arthritis in any of his joints. The first post-service relevant complaint of right wrist pain was in a December 1993 private treatment record from Dr. W.N.G., who diagnosed the Veteran with right carpal tunnel syndrome. Again, the Veteran's active duty ended in 1967. This lengthy period without treatment for the disorder weighs heavily against the claim. See Maxson, 12 Vet. App. at 453, aff'd, 230 F.3d at 1330. A February 1996 private treatment record from Dr. M.R.Z. reflects that the Veteran was again diagnosed with right carpal tunnel syndrome. In January 2005, the Veteran submitted a written statement from Dr. R.M.C., asserting that he had treated the Veteran from 1967 to 1993 for multiple disorders, to include osteoarthritis of the wrists. See a January 2005 statement from Dr. R.M.C. However, the Veteran's claims file is devoid of reports of X-ray testing completed by Dr. R.M.C., which are consistent with this statement. A May 2005 VA examination report reflects the Veteran's reports of pain in the right wrist; however, X-ray testing was not completed, and no diagnosis was rendered concerning the Veteran's right wrist. A December 2005 VA examination report reflects that the examiner noted that the Veteran utilized bilateral assistant devices on his wrists; however, the cause for this was not noted and no diagnoses were rendered regarding the wrist. The examiner also found the Veteran to have "multiple site arthralgia, which is due to periarticular and para-articular soft tissue inflammation and pain, including multiple sites of tendonitis and myositis." As above, a December 2005 VA examiner found that the Veteran had "multiple site arthralgia, which is due to periarticular and para-articular soft tissue inflammation and pain, including multiple sites of tendonitis and myositis" and opined that this "multiple site arthralgia" began in service. The Veteran was provided a VA examination in connection with his claim in June 2006. X-ray testing of the Veteran's wrists in connection with this examination did not reflect degenerative joint disease of either wrist; however, degenerative changes at the base of each metacarpal joint were present. At the examination, the Veteran reported heavy work with his hands, pulling on tow bars and moving planes, when he was onboard a ship during his active military service. The examiner stated that this type of work would put lots of wear on the wrist. A June 2008 VA general examination report reflects a diagnosis of carpal tunnel syndrome of the right wrist. The June 2008 VA examiner did not render a nexus opinion with regard to this diagnosis. In January 2010, the Board directed the RO to return the claims file to the examiner who conducted the December 2005 VA examination for clarification regarding which of the claimed joints were affected by the widespread arthralgia and which were affected by arthritis, confirmed on X-rays, or other medical disorders, and for an opinion addressing the etiology of all claimed joint disorders shown to exist. The opinion was obtained in June 2010. In the June 2010 VA opinion, the examiner reviewed the claims file, and noted that the Veteran was in a motor vehicle accident during his active military service. The examiner stated that the Veteran's X-rays document degenerative joint disease of the bilateral wrists. The examiner pointed out that "[a]ny arthritis appears to be related to wear and tear of the aging process." Therefore, the examiner determined that it is less likely than not that the Veteran's arthritis (no joints specified) is related to his active military service. The Board, in its March 2012 remand, pointed out that the June 2010 VA examiner discussed some, but not all, of the disorders at issue in this case, did not address which joints were affected by the widespread arthralgia, did not address many pertinent medical findings of record (the June 2010 VA examiner appears to have reviewed the STRs and December 2005 VA examination report only), and did not provide rationale in ruling out a relationship between the disorders he discussed and the Veteran's service. Accordingly, the Board found this VA medical opinion to be inadequate, and remanded the claim for another VA examination and medical opinion. Upon remand, the Veteran was provided another VA examination in April 2012. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that it is less likely as not that the Veteran's current bilateral wrist disorders are proximately due to or caused by his active military service. The examiner reasoned that the Veteran's STRs contain no documentation of any visits or treatment for wrist problems at all. The examiner further stated that X-rays of the Veteran's wrists in 2006 showed no evidence of degenerative joint disease. Thus, the examiner found that service connection for the bilateral wrist disorders had not been substantiated. As above, in its April 2013 remand, the Board found that the April 2012 VA examination report was inadequate. Accordingly, the Board remanded for a new VA examination to be obtained. Upon remand, the Veteran was afforded another VA examination and medical opinion in June 2013. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that the Veteran's current bilateral wrist disorders are not related to his active military service. The examiner reasoned that there is no evidence in the STRs of any complaints of or treatment for related to the wrists. The examiner pointed out that the Veteran's military separation examination is negative for any wrist abnormalities, and no complaints pertaining to the wrist were noted in the Veteran's separation self-assessment medical questionnaire. The examiner further reasoned that there is no interim data proximate to discharge. Thus, the examiner could not establish chronicity, treatment, or diagnosis of a wrist disorder while the Veteran was on active duty. In summary, the examiner provided a negative nexus opinion. As previously mentioned, the third element of service connection requires medical evidence of a nexus between the current disorder and the in-service disease or injury. Here, the claims file currently contains only negative medical nexus opinions pertaining to the claimed bilateral wrist disorder. The Board notes that there is a positive medical opinion regarding arthritis in general; however, as stated above, the December 2005 VA examiner did not clarify which specific joints he was referring to his medical opinion, and thus the Board finds this opinion to be inadequate. The Veteran's claim was remanded for further development. Upon further VA examinations and medical opinions, the VA examiners found the right wrist joint, in particular, to not be related to the Veteran's active military service. There is no positive evidence to the contrary that specifically links the bilateral wrist disorders to the Veteran's active military service. The Board notes that the June 2006 VA examiner found that the Veteran's heavy in-service work would put lots of wear on the wrists. However, the examiner did not state whether the Veteran's current bilateral wrist disorders are directly related to this increased wear, or whether they are related to superseding causes. In contrast, the June 2013 VA examiner accurately and thoroughly characterized the evidence of record and conducted a comprehensive examination of the Veteran's bilateral wrist. His report of the Veteran's medical history and his clinical findings are consistent with the entire body of medical evidence of record. He provided a medical nexus opinion that directly and sufficiently finds that the Veteran's bilateral wrist disorders are not related to his active military service, and provides supporting rationale for this opinion. There is no basis on which to find that the report is incomplete or insufficient in any way. The VA and private treatment records do not provide contrary evidence. Thus, as the evidence is not in equipoise, service connection is not warranted. D. Bilateral Knee Disorders With regard to the bilateral knee disorders, as noted above, the first element of service connection requires medical evidence of a current disorder. Here, a current diagnosis has been established. On VA examination in June 2013, the Veteran was diagnosed with patellofemoral syndrome and patellofemoral degenerative joint disease of the right knee as well as patellofemoral syndrome and degenerative joint disease of the medial compartment of the left knee. Thus, the Veteran has satisfied the first element of service connection. As stated above, the second element of service connection requires medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease. Here, the Veteran's STRs are negative of any instance of complaints of and treatment for the knees. However, the Board observes that the Veteran was involved in a motor vehicle accident in August 1966. While the treatment records surrounding this event focus on injuries to the Veteran's head and low back, the Board concedes that such an accident likely resulted in trauma, however slight, to the Veteran's right knee. At his July 1967 military separation examination, his right knee was normal. His active military service ended in July 1967. Post-service, in a July 1967 report of medical history completed in connection with employment, shortly after the Veteran's separation from the active military service, the Veteran specifically denied experiencing pain or arthritis in any of his joints. In September 1976, the Veteran reported pain in his left knee to his private physician, but X-rays of the left knee were normal. A subsequent March 1985 private X-ray of the left knee was also normal. The first post-service relevant complaint of bilateral knee pain was in at the July 2003 VA examination, where X-ray testing showed patellofemoral degenerative joint disease of the right knee. Later that month, the Veteran underwent a private whole-body planar imaging test, which revealed "vague increased activity" in the right knee, which was "consistent with degenerative change[s]." See a July 2003 whole-body planar imaging test. Again, the Veteran's active duty ended in 1967. This lengthy period without treatment for the disorder weighs heavily against the claim. See Maxson, 12 Vet. App. at 453, aff'd, 230 F.3d at 1330. In January 2005, the Veteran submitted a written statement from Dr. R.M.C., asserting that he had treated the Veteran from 1967 to 1993 for multiple disorders, to include osteoarthritis of the knees. However, the Veteran's claims file and Virtual VA file are devoid of reports of X-ray testing completed by Dr. R.M.C., which are consistent with this statement. As above, a December 2005 VA examiner found that the Veteran had "multiple site arthralgia, which is due to periarticular and para-articular soft tissue inflammation and pain, including multiple sites of tendonitis and myositis" and opined that this "multiple site arthralgia" began in service. In January 2010, the Board directed the RO to return the claims file to the examiner who conducted the December 2005 VA examination for clarification regarding which of the claimed joints were affected by the widespread arthralgia and which were affected by arthritis, confirmed on X-rays, or other medical disorders, and for an opinion addressing the etiology of all claimed joint disorders shown to exist. The opinion was obtained in June 2010. In the June 2010 VA opinion, the examiner reviewed the claims file, and noted that the Veteran was in a motor vehicle accident during his active military service. The examiner stated that "[a]ny arthritis appears to be related to wear and tear of the aging process." Therefore, the examiner determined that it is less likely than not that the Veteran's arthritis (no joints specified) is related to his active military service. The Board, in its March 2012 remand, pointed out that the June 2010 VA examiner discussed some, but not all, of the disorders at issue in this case, did not address which joints were affected by the widespread arthralgia, did not address many pertinent medical findings of record (the June 2010 VA examiner appears to have reviewed the STRs and December 2005 VA examination report only), and did not provide rationale in ruling out a relationship between the disorders he discussed and the Veteran's service. Accordingly, the Board found this VA medical opinion to be inadequate, and remanded the claim for another VA examination and medical opinion. Upon remand, the Veteran was provided another VA examination in April 2012. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that it is less likely as not that the Veteran's current bilateral knee disorders are proximately due to or caused by his active military service. The examiner reasoned that the Veteran's STRs do not document any visits or treatment for knee problems. The examiner pointed out that X-rays taken at the examination of the knees showed arthritis. Thus, the examiner found that service connection for a bilateral knee disorder had not been substantiated. As above, in its April 2013 remand, the Board found that the April 2012 VA examination report was inadequate. Accordingly, the Board remanded for a new VA examination to be obtained. Upon remand, the Veteran was afforded another VA examination and medical opinion in June 2013. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that the current bilateral knee disorders are not related to the Veteran's active military service. The examiner reasoned that there is no evidence of any complaints or treatment related to the knees in the STRs. The examiner found that the Veteran's military separation examination was negative for any abnormalities of the knee on examination. The examiner also pointed out that there were no knee complaints documented on the Veteran's separation medical self-assessment questionnaire. The examiner stated that there is no interim data proximate to the Veteran's discharge. Thus, in summary, the examiner provided a negative medical nexus opinion. As previously mentioned, the third element of service connection requires medical evidence of a nexus between the current disorder and the in-service disease or injury. Here, the claims file currently contains only negative medical nexus opinions pertaining to the bilateral knee disorders. E. Bilateral Hip Disorders With regard to the bilateral hip disorders, as noted above, the first element of service connection requires medical evidence of a current disorder. Here, a current diagnosis has been established. At the June 2008 VA examination, the Veteran was diagnosed with bilateral hip sprain. On VA examination in June 2013, the Veteran was diagnosed with a bilateral hip strain and bursitis. Regarding arthritis of the bilateral hips, a private letter dated in November 2005 documents that the Veteran has been treated for arthritis. Additionally, the Veteran's VA Medical Center (VAMC) current diagnoses list includes "DJD." However, X-rays taken in December 2007 and April 2012, in conjunction with his VA examinations, were negative for arthritis of the bilateral hips. The remaining treatment records and examinations do not diagnose the Veteran with degenerative joint disease of the bilateral hips. However, based on his other current diagnoses, the Veteran has satisfied the first element of service connection. As stated above, the second element of service connection requires medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease. The Veteran's STRs are negative of any instance of complaints of and treatment for the hips. However, the Board observes that the Veteran was involved in a motor vehicle accident in August 1966. While the treatment records surrounding this event focus on injuries to the Veteran's head and low back, the Board concedes that such an accident likely resulted in trauma, however slight, to the Veteran's hips. Similarly, at the post-service April 2012 VA examination, the Veteran was diagnosed with "motor vehicle collision with back and hip injuries in 1964." At his July 1967 military separation examination, his bilateral hips were normal. Post-service, the first post-service relevant complaint pertaining to a bilateral hip disorder was in a private treatment record dated in September 1999. The Veteran complained of pain in his hip (a side was not identified), and he was found to be on unknown arthritis medication for his hip. Again, the Veteran's active duty ended in 1967. This lengthy period without treatment for the disorder weighs heavily against the claim. See Maxson, 12 Vet. App. at 453, aff'd, 230 F.3d at 1330. As above, a December 2005 VA examiner found that the Veteran had "multiple site arthralgia, which is due to periarticular and para-articular soft tissue inflammation and pain, including multiple sites of tendonitis and myositis" and opined that this "multiple site arthralgia" began in service. At the June 2008 VA general medical examination, the VA examiner diagnosed the Veteran with right hip sprain with negative X-ray testing showing arthritis in December 2007. The June 2008 VA examiner did not render a nexus opinion with regard to this diagnosis. In January 2010, the Board directed the RO to return the claims file to the examiner who conducted the December 2005 VA examination for clarification regarding which of the claimed joints were affected by the widespread arthralgia and which were affected by arthritis, confirmed on X-rays, or other medical disorders, and for an opinion addressing the etiology of all claimed joint disorders shown to exist. The opinion was obtained in June 2010. In the June 2010 VA opinion, the examiner reviewed the claims file, and noted that the Veteran was in a motor vehicle accident during his active military service. The examiner found that the Veteran's X-rays do not document arthritis in the hips. The examiner stated that "[a]ny arthritis appears to be related to wear and tear of the aging process." Therefore, the examiner determined that it is less likely than not that the Veteran's arthritis (no joints specified) is related to his active military service. The Board, in its March 2012 remand, pointed out that the June 2010 VA examiner discussed some, but not all, of the disorders at issue in this case, did not address which joints were affected by the widespread arthralgia, did not address many pertinent medical findings of record (the June 2010 VA examiner appears to have reviewed the STRs and December 2005 VA examination report only), and did not provide rationale in ruling out a relationship between the disorders he discussed and the Veteran's service. Accordingly, the Board found this VA medical opinion to be inadequate, and remanded the claim for another VA examination and medical opinion. Upon remand, the Veteran was provided another VA examination in April 2012. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that it is less likely as not that the Veteran's current bilateral hip disorders are proximately due to or caused by his military service. The examiner reasoned that the Veteran's STRs contain no documentation of any visits or treatment for any hip problems. The examiner stated that recent X-rays of the Veteran's hips, taken at the April 2012 examination, were negative for arthritis. Thus, the examiner found that service connection for bilateral hip disorders has not been substantiated. As above, in its April 2013 remand, the Board found that the April 2012 VA examination report was inadequate. Accordingly, the Board remanded for a new VA examination to be obtained. Upon remand, the Veteran was afforded another VA examination and medical opinion in June 2013. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that the Veteran's bilateral hip disorders are not related to his military service. The examiner reasoned that there is no evidence of any complaints or treatment for a hip disorder in the STRs. The examiner noted that there is evidence of a motor vehicle accident in 1966 in the STRs; however, the examiner pointed out that the complaints surrounding the accident are limited to the Veteran's back. The examiner stated that there is no indication of any treatment, complaints, or diagnosis of a hip disorder in the STRs. The examiner indicated that the Veteran's military separation examination is negative for any complaints related to the hip and no abnormalities were documented on that examination. The examiner found that he could not establish a hip disorder occurring during the Veteran's active military service. He stated that there is no interim data proximate to the Veteran's military discharge. Thus, in summary, the examiner provided a negative medical nexus opinion. As previously mentioned, the third element of service connection requires medical evidence of a nexus between the current disorder and the in-service disease or injury. Here, the claims file currently contains only negative medical nexus opinions pertaining to the bilateral hip disorders. E. All Disabilities The Board notes that there is a positive medical opinion regarding arthritis in general; however, as stated above, the December 2005 VA examiner did not clarify which specific joints he was referring to in his medical opinion, and thus the Board finds this opinion to be inadequate. The Veteran's claim was remanded for further development. Upon further VA examinations and medical opinions, the VA examiners found the claimed joints to not be related to the Veteran's active military service. There is no positive evidence to the contrary that specifically links the claimed joint disorders to the Veteran's active military service. Here, the June 2013 VA examiner accurately and thoroughly characterized the evidence of record, conducted a comprehensive examination of the Veteran's claimed joint disorders, and provided a medical opinion with supporting rationale. His report of the Veteran's medical history and his clinical findings are consistent with the entire body of medical evidence of record. There is no basis on which to find that the report is incomplete or insufficient in any way. The VA and private treatment records do not provide contrary evidence. Thus, as the evidence is not in equipoise, service connection is not warranted. The Board notes that the Veteran reports continuous symptomatology of his claimed joint problems since his active military service. However, the Veteran's contentions are not supported by the medical evidence of record. As stated above, the earliest post-service medical evidence showing right wrist complaints is dated in December 1993 (26 years after service) and the earliest post-service medical evidence showing left wrist complaints is dated in January 2005 (38 years after service). The earliest post-service medical evidence showing degenerative joint disease of the wrists is dated in June 2010 (43 years after service). The earliest post-service medical evidence showing degenerative joint disease of the knees is dated in July 2003 (36 years after service). The earliest post-service medical evidence showing hip complaints is dated in September 1999 (32 years after service). The Board notes that, in January 2005, the Veteran submitted a written statement from Dr. R.M.C., asserting that he had treated the Veteran from 1967 to 1993 for multiple disorders, to include osteoarthritis of the right shoulder, left hand, bilateral wrists, and bilateral knees. However, the Veteran's claims file is devoid of reports of X-ray testing completed by Dr. R.M.C., which are consistent with this statement. X-rays taken of the right shoulder in service were normal, and did not reveal arthritis of the right shoulder. At his July 1967 military separation examination, his claimed joints were found to be normal with no complaints of pain. The June 2013 VA examiner, following a review of the claims file and a physical examination of the Veteran, also found that he could not establish chronicity for these disorders. Thus, the Board finds that the evidence of record does not document continuity of symptomatology of degenerative joint disease of the right shoulder, left hand, bilateral wrists, and bilateral knees, both during and since the Veteran's active military service. Thus, the Board finds that the medical evidence does not establish a "chronic disorder." 38 C.F.R. § 3.303; see Walker, 708 F.3d at 1331. The Veteran's service connection claim cannot be granted on this theory of entitlement. Additionally, the Board finds that the Veteran is not entitled to presumptive service connection for degenerative joint disease of the right shoulder, left hand, bilateral wrists, and bilateral knees. As stated above, the earliest post-service medical treatment record diagnosing degenerative joint disease of any of these joints is dated in July 2003, and the Veteran was separated from the active duty in July 1967. No diagnosis of degenerative joint disease of these joints was made within one year of the Veteran's military discharge. Thus, the presumption for service connection for chronic diseases does not apply. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). In reaching this decision, the Board has considered the Veteran's arguments in support of his claim. The Board acknowledges that the Veteran is competent, even as a layperson, to attest to factual matters of which he has first-hand knowledge, e.g., an injury during his active military service. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that lay evidence is one type of evidence that must be considered, and that competent lay evidence can be sufficient in and of itself. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). In Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009), and in Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit determined that lay evidence can be competent and sufficient to establish a diagnosis of a disorder when: (1) a layperson is competent to identify the medical disorder (noting that sometimes the layperson will be competent to identify the disorder where the disorder is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (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. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient in a particular case is a fact issue. Id. Although the Veteran is competent to report that he injured his claimed joints during his active military service, which resulted in his current joint disorders, the Board must still weigh his lay statements against the medical evidence of record. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). In making this credibility determination, the Board does not find the Veteran's statements concerning the etiology of his claimed joint disorders to be credible, since his STRs make no reference to specific to the claimed joints, contain few complaints of joint pain, and do not document any abnormalities of the claimed joints on his military separation examination. Further, when the Veteran first sought post-service treatment for these disorders, he failed to mention any injury to these joints during his active military service. See Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996); see also Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). It is important to point out that the Board does not find that the Veteran's lay statements lack credibility merely because they are unaccompanied by contemporaneous medical evidence. See Davidson, 581 F.3d at 1313, quoting Buchanan, 451 F.3d at 1337 ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). Rather, the Veteran's statements are found to be incredible because they are inconsistent with the evidence of record, which fails to show a right shoulder injury during his active military service, which fails to show any abnormalities of the right shoulder on his military separation examination, and which contains only probative negative nexus medical opinions. For the reasons set forth above, the Board finds that the Veteran's lay statements that his symptoms have been present since his active military service are not credible. Therefore, these statements do not warrant a grant of service connection or a determination that further development of the medical evidence is required. All other evidence of record, aside from the Veteran's statements in support of his current claims, is unfavorable to the claim for service connection. The Board notes that under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran's claim, and thus that doctrine is not applicable. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's claim for service connection for a right shoulder disorder, a left hand disorder, bilateral wrist disorders, bilateral knee disorder, and bilateral hip disorders is not warranted. III. VA's Duties to Notify and Assist Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and, (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the Agency of Original Jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board finds that the content requirements of a duty-to-assist notice letter have been fully satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Letters from the RO dated in March 2003, November 2005, and September 2007 provided the Veteran with an explanation of the type of evidence necessary to substantiate his claims, as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. Letters dated in March 2006 and September 2007 also provided the Veteran with information concerning the evaluations and effective dates that could be assigned should service connection be granted, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). The majority of the duty-to-assist letters were not provided before the initial RO adjudication of his claims in March 2004 and July 2006. However, after he was provided the additional letters, the claims were then readjudicated in the March 2006, April 2007, March 2009, June 2011, October 2012, and July 2013 Supplemental Statements of the Case (SSOCs) based on any additional evidence received in response to those additional notice letters. This is important to point out because if there was no notice provided prior to the initial adjudication of the claim, or for whatever reason the notice provided was inadequate or incomplete, this timing error may be effectively "cured" by providing any necessary notice and then going back and readjudicating the claim, including in a Statement of the Case (SOC) or SSOC, such that the intended purpose of the notice is not frustrated and the Veteran is given ample opportunity to participate effectively in the adjudication of his claim. In other words, here, this timing error in the provision of the notice is ultimately inconsequential and, therefore, at most nonprejudicial, i.e., harmless error. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). For all of these reasons, the Board concludes that the appeal may be adjudicated without a remand for further notification. VA also has a duty to assist the Veteran in the development of the claims. This duty includes assisting the Veteran in the procurement of (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issues has been obtained. His STRs, personnel records, VA treatment records, and private treatment records have been obtained. The claims file does not present evidence that the Veteran is currently receiving disability benefits from the Social Security Administration (SSA) for the disorders currently on appeal. Therefore, the Board does not need to make an attempt to obtain these records. The Board does not have notice of any additional relevant evidence that is available but has not been obtained. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on a claim, as defined by law. The record indicates that the Veteran participated in VA examinations in July 2003, May 2005, December 2005, June 2006, March 2007, June 2008, April 2012, and June 2013, the results of which have been included in the claims file for review. While, as above, the earlier VA examination have been deemed to be inadequate, the June 2013 VA examiner reviewed the claims file, and thoroughly examined of the Veteran and supported his opinions by sufficient rationale. Therefore, the Board finds that the June 2013 VA examination and medical opinion is adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claims. The Board is also satisfied as to substantial compliance with its January 2010, March 2012, and April 2013 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). These remands included scheduling the Veteran for additional VA examinations and medical opinions, which he had in June 2010, April 2012, and June 2013. The April 2013 remand also included obtaining the Veteran's recent VA treatment records, which were obtained and associated with his Virtual VA claims file. The recent remand also directed the AMC to obtain the X-rays from the April 2012 VA examination. The X-rays were obtained and associated with the Veteran's Virtual VA claims file. The recent remand also included sending the Veteran a letter, and providing him the appropriate release form (VA Form 21-4142) to obtain his confidential records from his private physician. This letter was provided in April 2013; however, the Veteran did not return the release forms, and all other evidence that he has indicated as relevant to his claims has been obtained. Finally, the remands included readjudicating the claims, which was accomplished in the June 2011, October 2012, and July 2013 SSOCs. Thus, the Board finds that there has been substantial compliance with its remand directives. Id. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. ORDER Service connection for a right shoulder disorder is denied. Service connection for a left hand disorder is denied. Service connection for a bilateral wrist disorder is denied. Service connection for a bilateral knee disorder is denied. Service connection for a bilateral hip disorder is denied. ____________________________________________ APRIL MADDOX Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs