Citation Nr: 1327870 Decision Date: 08/30/13 Archive Date: 09/05/13 DOCKET NO. 09-16 899 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for cervical myelopathy with cervical disk disease, post C5-C6 discectomy and cervical fusion. 2. Entitlement to service connection for degenerative disk disease of the lumbar spine, including at L2-3. 3. Entitlement to service connection for post-traumatic osteoarthritis of the right knee. 4. Entitlement to service connection for osteoarthritis at multiple sites. 5. Entitlement to service connection for osteoarthritis of the left pelvic region and thigh. 6. Entitlement to service connection for osteoarthritis of the right pelvic region and thigh. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. M. Donahue, Associate Counsel INTRODUCTION The Veteran served on active duty from June 16, 1978, to January 12, 1979; on September 21, 2001; from March 1, 2002, to April 1, 2002; and from November 22, 2002, to December 4, 2002. He separated from service in approximately November 2006 with almost 30 years of active duty, active duty for training, and inactive duty training with the United States Air Force and Minnesota National Guard. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. In May 2010, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge. A transcript of this hearing was prepared and associated with the claims file. Additionally, the Veteran through his testimony, with the assistance of his representative, demonstrated actual knowledge of the elements necessary to substantiate the claims. See Bryant vs. Shinseki, 23 Vet. App. 488 (2010). A copy of the hearing transcript has been associated with the claims folder. In August 2010 and October 2012, the Board remanded the Veteran's claims for additional VA examinations. The Veteran underwent VA examinations in October 2010 and January 2013. Accordingly, the Veteran's VA claims folder has been returned to the Board for further appellate proceedings. The Board finds substantial compliance with the requirements articulated in the Board's prior remand decision. See Stegall v. West, 11 Vet. App. 268 (1998); see D'Aries v. Peake, 22 Vet. App. 97, 104 -05 (2008); Dyment v. West, 13 Vet. App. 141 (1999). FINDINGS OF FACT 1. Cervical myelopathy with cervical disk disease, post C5-C6 discectomy and cervical fusion, was not present during active duty, active duty for training or inactive duty for training; arthritis of the back was not manifested within one year after the Veteran's extended period of active duty; and no back disability is etiologically related to active duty, active duty for training, or an injury during inactive duty for training. 2. Degenerative disk disease of the lumbar spine, including at L2-3, was not present during active duty, active duty for training or inactive duty for training; arthritis of the back was not manifested within one year after the Veteran's extended period of active duty; and no back disability is etiologically related to active duty, active duty for training, or an injury during inactive duty for training.. 3. Post-traumatic osteoarthritis of the right knee was not present during active duty, active duty for training or inactive duty for training; arthritis of the back was not manifested within one year after the Veteran's extended period of active duty; and no back disability is etiologically related to active duty, active duty for training, or an injury during inactive duty for training. 4. Entitlement to service connection for osteoarthritis at multiple sites was not present during active duty, active duty for training or inactive duty for training; arthritis of the back was not manifested within one year after the Veteran's extended period of active duty; and no back disability is etiologically related to active duty, active duty for training, or an injury during inactive duty for training. 5. Entitlement to service connection for osteoarthritis of the left and right pelvic regions and thighs was not present during active duty, active duty for training or inactive duty for training; arthritis of the back was not manifested within one year after the Veteran's extended period of active duty; and no back disability is etiologically related to active duty, active duty for training, or an injury during inactive duty for training. CONCLUSIONS OF LAW 1. Cervical myelopathy with cervical disk disease, post C5-C6 discectomy and cervical fusion, was not incurred in, or aggravated by, active service, or active or inactive duty for training. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131 (West 2002); 38 C.F.R. §§ 3.6, 3.303 (2012). 2. Degenerative disk disease of the lumbar spine, including at L2-3, was not incurred in, or aggravated by, active service, or active or inactive duty for training. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309 (2012). 3. Post-traumatic osteoarthritis of the right knee was not incurred in, or aggravated by, active service, or active or inactive duty for training. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309 (2012). 4. Osteoarthritis at multiple sites was not incurred in, or aggravated by, active service, or active or inactive duty for training. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309 (2012). 5. Osteoarthritis of the left pelvic region and thigh was not incurred in, or aggravated by, active service, or active or inactive duty for training. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309 (2012). 6. Osteoarthritis of the right pelvic region and thigh was not incurred in, or aggravated by, active service, or active or inactive duty for training. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. Veterans Claims Assistance Act of 2000 (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that 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. A VCAA letter dated in September 2008, fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was aware that it was ultimately his responsibility to give VA any evidence pertaining to the claims. The letter informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. Furthermore, the letter described how appropriate disability ratings and effective dates were assigned. The Board also concludes VA's duty to assist has been satisfied. The Veteran's available service treatment records and relevant VA medical records are in the file. The Board finds that all relevant records identified by the Veteran as relating to this claims have been obtained, to the extent possible. The record contains sufficient evidence to make a decision on the claims. VA has fulfilled its duty to assist. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). In this case, the Veteran was provided VA examinations in November 2008, October 20102, and January 2013. The January 2013 examiner considered the Veteran's claims of experiencing symptoms of pain while on active duty, as well as the service treatment records, post-service treatment records, and conducting a physical examination. The examiner concluded that the claimed disorder was less likely than not incurred in or caused by the Veteran's service. Therefore, as the opinion was based on review of the claims file, including the Veteran's statements and other material favorable to the Veteran's claims, and provided an extensive rationale for the opinion provided, the Board concludes that the opinion provided is adequate. Given the foregoing, the Board finds the evidence of record to be thorough, complete, and sufficient upon which to base a decision with respect to the Veteran's claim. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As such, the Board finds that the medical evidence of record is sufficient to adjudicate the Veteran's claim. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Active military, naval, or air service includes active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty. 38 C.F.R. § 3.6(a). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 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. The presumption pertaining to chronic diseases under 38 U.S.C.A. § 1112, however, does not apply to ACDUTRA or INACDUTRA service. Smith v. Shinseki, 24 Vet. App. 40, 46-47 (2010); see also Acciola v. Peake, 22 Vet. App. 320 (2008); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). Nor does the presumption of sound condition at entrance into service or presumption of aggravation during service of preexisting diseases or injuries which undergo an increase in severity during service apply to periods of ACDUTRA or INACDUTRA unless an examination was conducted prior to the period of ACDUTRA or INACDUTRA. See Smith, 24 Vet. App. at 45. An alternative method of establishing the second and third elements of service connection for those disabilities identified as a "chronic condition" under 38 C.F.R. § 3.309(a) is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A claimant can establish continuity of symptomatology with competent evidence showing: (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between a current disability and the post-service symptomatology. 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Factual Background The Veteran seeks service connection for osteoarthritis at multiple locations. He maintains that his claimed disabilities were incurred in or aggravated by military service to include INACDUTRA. He has also argued that his more recent duty contributed to his claimed back disability. The Veteran's service treatment records for his first period of service are negative for complaints or treatments related to a low back disability. In a July 1980 clinic note, the Veteran complained that he caught his foot between two rocks and fractured his foot. In an October 2002 private treatment record, the Veteran complained of pain in his right knee and hip and numbness in his right hand. He stated that this all began approximately three weeks ago. He was working on loading pumpkins at about 2 in the morning with his brother-in-law and the next morning he began having numbness in the right hand intermittently. He had no had this before. He also began having right hip and knee pain. He has pains daily. His right hip and knee pain is significantly improved. He has had no history of recurrent neurological problems in the past. The diagnoses were right hip strain and right knee strain. In May and June 2003 private orthopedic notes, the Veteran complained of a significant history of pain. He reported cervical spine and shoulder pain for five to six months and right knee pain with some locking and mechanical symptoms since October 2002. X-ray testing of the knees showed minimal arthritic changes at the patellofemoral joint and some mild narrowing, but were noted as fairly symmetrical joint surfaces between the right and left sides. During follow-up, the examiner noted the Veteran underwent an MRI which showed no arthritic spur formation and no meniscal tear. A February 2005 x-ray report of the lumbar spine found mild levoscoliosis. A June 2005 x-ray report of the pelvis found degenerative changes on both hips, left more so than the right. An October 2005 clinic noted included a diagnosis of polyarthropathies. The Veteran complained of feeling of multiple joint aches, worse with cold, wet weather. He reported he thinks he may have some degenerative joint disease and osteoarthritis. In a December 2005 neurology report, the Veteran was evaluated for neurological difficulties. He underwent an electromyography of the right lower extremity which suggested that his complaint of lower extremity weakness was the result of a CNS/upper motor neuron disorder, rather than radiculopathy or neuropathy. The Veteran was not sure when he developed symptoms in the lower extremity, but he assumed that this started after he tripped over a tent guy about two years ago. At that time, there was some associated low back pain and paresthesia. In a January 2006 private treatment record, the Veteran reported his symptoms have been coming on gradually over the last two and a half years. A January 2006 neurosurgery spine consultation states that the onset of the Veteran's cervical myelopathy was spontaneous. The Veteran underwent a cervical spine discectomy and fusion of C5-6 and C6-7 levels in January 2006. The clinic treatment records from March 2006 and April 2006 expressly demonstrate that the Veteran sought medical treatment after he slipped on ice and fell on his back while on active duty for training or inactive duty training. In the March 2006 note, the Veteran reported he had a small amount of pain and stiffness in the cervical region, though there were no obvious signs of injury. One March 2006 private treatment record notes that 'Prior to the fall, he was having very little, if any, post-surgical pain and was improving nicely in physical therapy,' and that he has developed 'right knee pain, exacerbation of osteoarthritis due to a fall on 3/23/06.' In a May 2006, the Veteran underwent right knee arthroscopic partial medial menisectomy and debridement with chondroplasty, tricompartmental for medial meniscal tear and degenerative joint disease. According to a November 2006 Report of Medical Examination that found the Veteran medically disqualified for worldwide duty, the Veteran's medical history was unremarkable until 2002. This record notes that the Veteran was found to have a sprain to the hip/thigh and right knee pain with some locking and mechanical symptoms in 2002. A May 2003 MRI showed localized chondromalacia and the Veteran was informed that he probably had early osteoarthritis of the right knee. It was noted that his low back pain started in February 2005 and that diffuse arthritic disc changes were shown at L2-3, L4-5, and L5-S1. Bilateral degenerative hip changes were shown on x-ray in June 2005. It was noted that the Veteran was experiencing more cervical spine pain with abnormal gait in October 2005 and that he reported having had these symptoms for 2.5 years. An MRI showed advanced degenerative changes of the cervical spine, and surgery was performed in January 2006. His stumbling gait was noted to be better at his one-month follow up. During a November 2008 VA examination, the Veteran reported his symptoms in the low back started in 2002. He was not having any neck pain at that time. The Veteran was treated for a lumbar strain with associated right sciatica. His low back and right lower leg progressed in 2005 and x-ray testing revealed mild levoscoliosis with degenerative changes, as well as degenerative changes of both hips. In November 2005, the Veteran was referred to a rheumatologist, who referred him to neurology. The examiner noted he reviewed the December 2005 note in which the Veteran reported he "tripped over a tent guy", but noted there is no military documentation of any associated injury, and it was the neurologist's impression at that time that the Veteran presented with a central nervous system disease with resultant spasticity, weakness, and hyperreflexia. After a physical examination, the examiner determined that the Veteran's cervical condition is less likely than not caused by service. The examiner noted that his service medical records and his civilian record through 1998 were normal. The examiner found that the Veteran's cervical myelopathy is less likely as not caused by service or any service-connected injury as there was no service injury documented during his military history. The examiner noted that most of the problems with the Veteran's low back started while he was serving as a civil service technician. There is no documentation of any low back injury in service; therefore, the Veteran's back disorder was is less likely as not caused by service. Additionally, there is no military documentation of any right hip or any other associated orthopedic problems or events, just civilian documentation of neck, low back, hips and right knee. Due to the lack of any military service documentation for any military injury or service-connected injury, the Veteran' right hip, left hip, and right knee conditions are less likely as not caused by service. In an April 2009 statement, D. M., M.D., indicated that the Veteran has degenerative disease affecting his spine. Based on his descriptions of the work that he performed while in the military, it is at least as likely as not that the condition can be partially attributed to the duties that he performed while in service in the line of duty. In a May 2009 opinion, J. Z., M.D., the Veteran's treating physician, indicated that the Veteran is disabled secondary to cervical, thoracic, and lumbar pain syndromes and also osteoarthritis in his right knee. He stated that his service is related to his disabilities and also a substantial cause of his degenerative disk disease in his lumbar and thoracic spine, and probably in regard to his posttraumatic osteoarthritis of his right knee. An October 2010 VA examiner conducted an interview of the Veteran, reviewed the claims file, and conducted an examination. He also reviewed the Veteran's reported in-service injuries including slipping on ice in March 2006. After considering the foregoing, the examiner diagnosed the Veteran with the following: cervical myelopathy associated with cervical disk disease; traumatic injury to the lumbosacral spine with degenerative disk disease L2-3 and with three disk herniations; traumatic injury to the right hip with trochanteric bursitis; and traumatic injuries to the right knee with anterior derangement and chondromalacia, status post arthroscopic surgery with medial meniscectomy and chondroplasty. He concluded that 'I cannot really come up with a service connection for any of the material that I did today or for that matter, the other hip and knee (the same situation exists for these as well) without a great deal of speculation.' During a January 2013 VA examination, the Veteran was evaluated for his multiple orthopedic complaints. The claims file was reviewed and the Veteran underwent physical examinations. The examiner noted a diagnosis of cervical myelopathy with cervical disc disease, post C5-6 discectomy. The Examiner found that the symptoms initially developed three weeks prior to October 14, 2002 while lifting pumpkins. There is evidence that the Veteran was on active duty for several months in 2001 and November 2002, therefore the onset of symptoms were not during the Veteran's active service. The examiner noted that there is no history of neck trauma during military service. MRI and x-ray findings in the cervical spine prior to surgery indicate that he degenerative changes in the midportion of the anterior cervical spine are most chronic degenerative changes which had been developing over an undetermined number of years. This pattern of localized accelerated degenerative changes without identifiable etiology is typical for spinal stenosis, and therefore, most likely not related to individual factors and not active duty military service. The examiner also reviewed and examined the Veteran for his additional claims. The examiner determined that multilevel degenerative change of the thoracolumbar spine was less likely as not caused or aggravated by active military service. The examiner noted that though the Veteran had a slip and fall injury in March 2006, there was documentation of mild multilevel degenerative change prior to that date. There was no medical record evidence that the fall in March 2006 resulted in any permanent injury. Current clinical evaluation of the back was essentially normal. Mild multilevel degenerative changes are consistent with normal age-related degenerative change. The examiner noted no diagnosis of a right hip disorder. The examiner found minimal degenerative changes of the left hip are most likely related to normal age-related degenerative change. The examiner found minimal patellar spurring was less likely as not caused by or the result of military service as the spurring is present bilaterally indicating that this is most likely a normal age-related degenerative change and not related to specific injury or trauma to one knee. The Veteran reported he had no other joint pains or conditions other than those readdressed. He states that he has never been diagnosed or treated with a rheumatologic or autoimmune joint conditions and does not believe he has any such condition at this time. The examiner reviewed the claims file and noted the April 2006 note which included a diagnosis of "polyarthropathy, mild" with no evidence or rational to support the diagnosis. The examiner noted diagnoses of degenerative arthritis as previously noted at bilateral knees, left hip, cervical and thoracolumbar spine. These conditions are most likely related to normal age-related degenerative change and not secondary to or aggravated by military service. The examiner noted degenerative changes were seen on x-ray were within the range of normal with no claims file documentation of significant localized trauma to these areas during active military service. Analysis Initially, the Board has considered the merits of the Veteran's claims, but finds that the facts of the case do not support an allowance for VA compensation for his orthopedic disabilities. First, it appears that the Veteran is asserting that his civilian employment in the Army National Guard as well as a member of the Army National Guard is identical to being on full-time active duty in the National Guard for purposes of establishing service connection for his claimed disabilities. However, the applicable law does not provide any basis to allow him to be awarded VA compensation for any disabilities that may relate to his civil employment in the Army National Guard. He can only be service connected for a disability that was incurred in active service, or disability that was the result of a disease or injury incurred or aggravated in the line of duty during ACDUTRA (38 U.S.C.A. § 101(24)(B)), or disability that was the result of an injury incurred or aggravated in the line of duty during INACDUTRA. That said, the Board recognizes that the Veteran has a current diagnoses of cervical myelopathy with cervical disk disease, post C5-C6 discectomy and cervical fusion, degenerative disk disease of the lumbar spine, including at L2-3, post-traumatic osteoarthritis of the right knee, osteoarthritis at multiple sites, and osteoarthritis of pelvic regions and thighs. The Board has considered the contentions of the Veteran and his representative that his claimed disabilities are a result of his period of active military service or incurred by an injury during INACDUTRA, but finds that service connection is not warranted for his musculoskeletal disabilities because the persuasive evidence of record provides no nexus or link to his period of active military service. As noted above, the medical evidence does not reflect the presence of a back, neck, hip, or knee disabilities during the Veteran's initial period of active service, and the Veteran does not contend that his disorders are due to his initial active duty service. Post-service medical records, as noted above, show a diagnosis of levoscoliosis, arthritic changes of the right knee, degenerative changes of the hips, and cervical myelopathy as early as 2003. However, as the diagnoses were made more than 22 years after the Veteran was discharged from active duty, it cannot be presumed to be related to service. The Board also notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). The Board has considered the Veteran's representative's July 2013 contentions that the Veteran's cervical myopathy and arthritis should be afforded presumptive service connection. However, there is no presumption for "other organic diseases of the nervous system" or arthritis for periods less than 90 days to include September 21, 2001; from March 1, 2002, to April 1, 2002; and from November 22, 2002, to December 4, 2002. Furthermore, as noted above, the presumption of soundness and presumption service-connectable disorders are no applicable to periods of ACDUTRA or INACDUTRA where, as here, the Veteran was not given an examination at the start of the period of service. Significantly, the record also includes no competent medical opinion establishing a nexus or medical relationship between the Veteran current osteoarthritis disorders diagnosed post-service and events during the Veteran's active service. In that regard, the Board finds the January 2013 VA medical opinion to be of significant probative value as it was definitive, based upon a complete review of the Veteran's entire claims file, and supported by detailed rationale. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). In contrast, the April 2009 and May 2009 opinions from the Veteran's treating physicians were not supported be adequate rationale, nor based upon a complete review of the Veteran's entire claims file. Consequently, the Board finds that entitlement to service connection for degenerative arthritis of the back, neck, hips, and right knee is not warranted. Further, there is no competent and persuasive evidence of a nexus between the Veteran's current back disability and a March 2006 injury during INACDUTRA. There is clear and convincing evidence that neck and back disorders pre-dated the March 2006 slip and fall, as at that time, the Veteran already carried diagnoses of mild levoscoliosis of the back and cervical myelopathy. There also is no persuasive medical opinion to support the claim that any pre-existing disorder was caused or aggravated by the March 2006 injury. Significantly, the Board notes that the only competent and persuasive medical opinion to directly address whether there exists a medical nexus between current back disability and service weighs against the Veteran's claim. The January 2013 VA examiner, after a review of the claims file, found that there was no medical record evidence that the fall in March 2006 resulted in any permanent injury. The Board finds that the January 2013 examiner's opinion constitutes probative and dispositive evidence on the medical nexus question. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) ('It is the responsibility of the BVA to assess the credibility and weight to be given the evidence') (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). Likewise, the Board notes that neither the Veteran nor his representative has presented, identified, or even alluded to the existence of any such evidence or opinion in support of his service connection claims on the basis of aggravation or worsening by the March 2006 injury. The Board has carefully considered the statements regarding the Veteran's back, neck, hip and knee disabilities. While the Board does not doubt the sincerity of his belief that his current disorders are a result of his active service, these claims turn on a medical matter. Though the Veteran may be competent to testify as to the sensory perceptions of his current disorder, questions of medical diagnosis and causation are within the province of medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). Lay persons are limited to attesting to factual matters of which they have first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). As a layperson without the appropriate medical training or expertise, the Veteran is not competent to render a probative opinion on such a medical matter. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ('a layperson is generally not capable of opining on matters requiring medical knowledge'). Here, while the Veteran is competent to say he had pain in service, the Veteran is not competent to say that his current back, neck, hip and knee disorders were the result of an injury in service. Hence, the submitted assertions in this regard do not constitute persuasive evidence in support of the claims for service connection. The Board has given the Veteran's statements of record every consideration. However, the Board does not find them credible as there are inconsistencies that diminish the reliability of the Veteran's current claim. For example, in a December 2005 private neurology report, the Veteran stated he was not sure when he developed symptoms in the lower extremity, but he assumed that this started after he tripped over a tent guy about two years ago. However, in a May and June 2003 private orthopedic note, the Veteran reported right knee pain since October 2002, when he was loading pumpkins. Based on the Veteran's conflicting statements, the Board finds that he is not credible to the extent that he reports the onset of the back disorder at issue to have been in service. Credible testimony is that which is plausible or capable of being believed. See Indiana Metal Prods. v. NLRB, 442 F.2d 46, 52 (7th Cir.1971) (citing Lester v. State, 212 Tenn. 338, 370 S.W.2d 405, 408 (1963)); see also Weliska's Case, 125 Me. 147, 131 A. 860, 862 (1926); Erdmann v. Erdmann, 127 Mont. 252, 261 P.2d 367, 369 (1953) ('A credible witness is one whose statements are within reason and believable....'). The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character. See State v. Asbury, 187 W.Va. 87, 415 S.E.2d 891, 895 (1992); see also Burns v. HHS, 3 F.3d 415, 417 (Fed.Cir.1993) (testimony was impeached by witness' 'inconsistent affidavits' and 'expressed recognition of the difficulties of remembering specific dates of events that happened ... long ago'); Mings v. Department of Justice, 813 F.2d 384, 389 (Fed.Cir.1987) (impeachment by testimony which was inconsistent with prior written statements). Although credibility is often defined as determined by the demeanor of a witness, a document may also be credible evidence. Caluza v. Brown, 7 Vet.App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). Under these circumstances, the Board must conclude that the claims for service connection must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for cervical myelopathy with cervical disk disease, post C5-C6 diskectomy and cervical fusion is denied. Entitlement to service connection for degenerative disk disease of the lumbar spine, including at L2-3, is denied. Entitlement to service connection for post-traumatic osteoarthritis of the right knee, is denied. Entitlement to service connection for osteoarthritis at multiple sites is denied. Entitlement to service connection for osteoarthritis of the left pelvic region and thigh is denied. Entitlement to service connection for osteoarthritis of the right pelvic region and thigh is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs