Citation Nr: 1328408 Decision Date: 09/05/13 Archive Date: 09/16/13 DOCKET NO. 04-07 028A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUE Entitlement to service connection for a lumbar spine disability (back disability), to include as secondary to a service-connected disability. [The issues of entitlement to an effective date earlier than August 27, 2007 for the grant of service connection for Raynaud's disease, entitlement to service connection for a left hip disability, entitlement to service connection for an acquired psychiatric disability, entitlement to an increased initial rating for Raynaud's disease of the left foot, and entitlement to a total disability rating based on individual unemployability due to service-connected disabilities will be addressed in a separate decision.] REPRESENTATION Appellant (the Veteran) is represented by: Lori Chism, Attorney ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from November 1973 to November 1975. This appeal comes before the Board of Veterans' Appeals (Board) from a March 2009 Order of the United States Court of Appeals for Veterans Claims (CAVC). The appeal originates from an April 2006 rating decision of the RO in Waco, Texas. In a decision dated in December 2007, the Board denied service connection for a lumbar spine disability. The Veteran appealed that decision to the CAVC. In an Order dated in March 2009, pursuant to a Joint Motion for Remand, the CAVC vacated that portion of the Board's December 2007 decision which denied service connection for a lumbar spine disability, and remanded the issue to the Board for development consistent with the Joint Motion. The Board's decision regarding the appropriate disability rating for cold injury residuals of the upper extremities was not disputed in the Joint Motion and is not a subject of the CAVC's Order. In May 2009, the Board remanded the issue of entitlement to service connection for a lumbar spine disability to the RO for evidentiary development as necessary to comply with the CAVC's Order. The appeal has since been returned to the Board for further appellate action. The Board notes that the Veteran's original attorney in this appeal attempted to withdraw from the case in February 2013. While this is after certification of this appeal, and VA regulations limit the ability of representatives to withdraw after certification, see 38 C.F.R. § 20.608 (2012), the Veteran subsequently appointed a new attorney as his representative, and specified that the appointment was without limitation of consent, delaying the appeal. A claimant may revoke a power of attorney at any time, and may discharge an agent or attorney at any time. Unless a claimant specifically indicates otherwise, the receipt of a new power of attorney executed by the claimant and the organization or individual providing representation shall constitute a revocation of an existing power of attorney. See 38 C.F.R. § 14.631 (2012). Thus, the April 2013 VA Form 21-22a serves to revoke the previous power of attorney and to appoint the new power of attorney with respect to all issues. Nevertheless, it appears that a fee agreement is still active regarding the Veteran's former attorney with regard to this appeal. It is for this reason that separate decisions have been rendered with respect to the issues currently on appeal. In reviewing this case the Board has not only reviewed the physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the appeal has been accomplished. 2. Although the Veteran sustained a lumbar sprain/strain in service, there was no chronic disability of the lumbar spine at service separation. 3. Arthritis of the lumbar spine did not become manifest to a degree of 10 percent or more within one year of service separation; symptoms of arthritis of the lumbar spine were not continuous after service. 4. No current disability of the lumbar spine is related to service. CONCLUSION OF LAW A lumbar spine disability was not incurred in service; arthritis of the lumbar spine is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran is seeking service connection for a lumbar spine disability on the basis that it is either related to service or to a service-connected disability. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The CAVC has held that "Congress specifically limits entitlement for service- connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Service connection may also be established the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App.439, 448 (1995). Under the regulation in effect at the time the Veteran filed his claim, service connection may be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (as in effect prior to October 10, 2006). That regulation was interpreted to permit service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation to a nonservice-connected disability by a service-connected disability. Allen, 7 Vet. App. at 448 (1995). Certain specific conditions are considered "chronic" diseases under VA Law. These include the following: Anemia, primary; Arteriosclerosis; Arthritis; Atrophy, progressive muscular; Brain hemorrhage; Brain thrombosis; Bronchiectasis; Calculi of the kidney, bladder, or gallbladder; Cardiovascular-renal disease, including hypertension. (This term applies to combination involvement of the type of arteriosclerosis, nephritis, and organic heart disease, and since hypertension is an early symptom long preceding the development of those diseases in their more obvious forms, a disabling hypertension within the 1- year period will be given the same benefit of service connection as any of the chronic diseases listed); Cirrhosis of the liver; Coccidioidomycosis; Diabetes mellitus; Encephalitis lethargica residuals; Endocarditis. (This term covers all forms of valvular heart disease); Endocrinopathies; Epilepsies; Hansen's disease; Hodgkin's disease; Leukemia; Lupus erythematosus, systemic; Myasthenia gravis; Myelitis; Myocarditis; Nephritis; Other organic diseases of the nervous system; Osteitis deformans (Paget's disease); Osteomalacia; Palsy, bulbar; Paralysis agitans; Psychoses; Purpura idiopathic, hemorrhagic; Raynaud's disease; Sarcoidosis; Scleroderma; Sclerosis, amyotrophic lateral; Sclerosis, multiple; Syringomyelia; Thromboangiitis obliterans (Buerger's disease); Tuberculosis, active; Tumors, malignant, or of the brain or spinal cord or peripheral nerves; Ulcers, peptic (gastric or duodenal)(A proper diagnosis of gastric or duodenal ulcer (peptic ulcer) is to be considered established if it represents a medically sound interpretation of sufficient clinical findings warranting such diagnosis and provides an adequate basis for a differential diagnosis from other conditions with like symptomatology; in short, where the preponderance of evidence indicates gastric or duodenal ulcer (peptic ulcer). Whenever possible, of course, laboratory findings should be used in corroboration of the clinical data. 38 C.F.R. § 3.309(a). Where one of the above chronic diseases is shown to be chronic in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Where a veteran served 90 days or more during a period of war or after December 31, 1946, and any of the chronic diseases listed above becomes manifest to a degree of 10 percent within 1 year from date of termination of such service (for Hansen's disease (leprosy) and tuberculosis, within 3 years; multiple sclerosis, within 7 years), such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, 1 Vet. App. at 57. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The veteran's service treatment records reveal that the Veteran was treated for lumbalgia in September 1974. He was again treated for complaints that included low back pain in February 1975. The examiner noted that the Veteran had fallen on his hip while playing basketball. In this regard, it is important for the Veteran to understand that the question of the Veteran's honorable service or whether he did, in fact, injure his back playing basketball nearly 40 years ago is not at issue. The critical question is whether the Veteran's current back disability has any connection to this injury. In addressing this question, the Board must look to many facts during this nearly 40 year time frame, including the post-service injuries, the Veteran's prior statements, his medical record over these many years, and all medical opinions that support and refute his claim. In this regard, at the time of his injury, the Veteran complained that he could not bend over or move, but was OK if he stood straight up. The impression was a muscle spasm with pain magnified by cerebral mechanisms. The Veteran received additional treatment for a back sprain in March 1975. His separation examination report, dated in August 1975, shows that his spine and lower extremities were clinically normal. Thus, to the extent that symptoms of lumbar spine disability were noted in service, there was no lumbar spine disability at the time of service separation, providing some evidence against this claim. Moreover, to the extent that symptoms of arthritis were noted in service, such symptoms were not chronic in service. There were also no manifestations of lumbar spine arthritis within a year of service separation. Therefore service connection for lumbar arthritis is not presumed. After service, in June 1988, the Veteran sustained an on- the-job lifting injury (strain) (see September 27, 1988 report of D.R.Y., M.D.). The Veteran was lifting a 100- pound disc drive when he felt something pop in his lower back. The Veteran complained of chronic pain in his low back going down the right buttock into the posterior lateral aspect of the right thigh and into the leg, occasionally even to the foot. Importantly, it was noted that the Veteran "denies having any previous problems of a similar nature." Such a statement from the Veteran at this time provides highly probative evidence against his own claim before the Board at this time, clearly indicating that one of the strongest pieces of evidence that the was not a chronic back disability associated with the basketball injury during service is the Veteran's own prior statement in 1988. In July 1991, the Veteran fell while at his place of employment, and sustained injuries that included traumatic disc disease at L5-S1, and a herniated disc at L4 (see e.g., March 1995 report from R.W.E., M.D.; July 1996 VA spine examination report). A July 1996 VA examination report notes a history of two lumbar laminectomies, and contains diagnoses that included failed lumbar laminectomy syndrome. An August 1991 evaluation by Y.J.M, M.D. notes that the Veteran fell at work about two weeks prior and complained of severe lower back pain since then. An August 1991 MRI showed post-surgical changes at L4-5, evidence of recurrent disc herniation at L4-5, mild disc protrusion at L5-S1, and degenerative disc disease at L4-5 and L5-S1. An April 1992 evaluation from R.D., M.D. reveals a complaint of low back pain that radiates into the left thigh. It was noted that this had been a persistent problem since the lumbar laminectomy surgery in 1988. The Veteran had previously been involved in lifting weights and running and was very depressed at not being able to work out since his recent injury. An October 1992 evaluation from L.A.M., M.D. notes that the Veteran "was doing very well until July 8, 1991 when he was injured at work." Again, the Veteran's own statement provide highly factual probative evidence against this own claim. In October 1995, the Social Security Administration (SSA) determined that the Veteran was disabled as of July 1991, due to a primary diagnosis of "back injury." The decision notes a history of low back injuries in 1988 with surgery at L4-L5, and in 1991. Importantly, once again, the Veteran's service was not cited by SSA or noted by the Veteran himself, undermining the Veteran's recollection of events and his credibility with the Board regarding all claims. In May 1998, the Veteran was involved in a motor vehicle accident (see June 8, 1998 and August 2, 1998 reports of J.V.B., D.C.). The Veteran reported lumbar pain with central and right lumbosacral pain with radiation of pain to the right buttocks to the right posterior thigh to the anterior calf area to the foot. Thus, the post-service evidence clearly demonstrates that the Veteran not only injured his back on multiple occasions after service separation, but that while being examined following the 1988 injury, he denied having any prior symptoms of a similar nature, and he reported in April 1992 that, prior to 1988, he had been involved in lifting weights and running. The Veteran's statements to this point to health care providers after service provide what only can be seen as overwhelming evidence against his own claim. The record includes several nexus opinions regarding the lumbar spine. The Veteran's former attorney cited to a medical opinion quoted in an unrelated Board decision for the proposition that an "injury to the lumbar area at such an early time in someone's life is more than likely to cause weakness and promote degeneration of the structures more readily than normal." While it does not appear that the Board decision was cited for its precedential value, the Board notes that Board decisions are not precedential and are decided on the individual facts of the case. 38 C.F.R. § 20.1303 (2012) The Veteran subsequently submitted a November 2006 opinion from his private physician, D.O.N, M.D., which peculiarly mirrors the language cited in the Board decision. D.O.N. noted that the Veteran had several service-connected injuries and disability, including lumbar injury. "[s]uch an injury to the lumbar spine at a fairly young age is likely to result in and promote degeneration of the spinal structures as the years progress." A May 2007 VA examination report includes the opinion that it was "less than likely" that the Veteran's lumbar spine conditions were related to his cold injury residuals but were rather related to on-the-job injuries. The rationale was that the Veteran's hands showed no sign of significant weakness or deformity that would support his contention that his cold injuries caused the fall from a ladder in 1991. A July 2009 VA examination included opinions on direct and secondary service connection. The examiner diagnosed degenerative disc disease status post lumbar fusion. The examiner could find nothing in the orthopedic literature indicating degenerative disc disease being caused by residuals of a cold injury that occurred 20 or more years prior. The examiner acknowledged the in-service low back strain. The Veteran also acknowledged the post-service injuries. The examiner opined that the Veteran's current lumbar spine condition is less likely as not related to his treatment in service for a lumbar strain. The examiner reasoned that there is nothing in the orthopedic literature indicating that an isolated lumbar strain will cause degenerative disc disease in the lumbar spine. The current lumbar spine condition was also found to be unrelated to the Veteran's service-connected cold injury. Rather, the examiner found that the spine disability is more likely related to the on-the-job injuries. It is the Board's responsibility to evaluate the evidence and to assign each report or opinion its due probative weight. Owens v. Brown, 7 Vet. App. 429, 433 (1995). In reviewing the evidence, the Board is free to favor one medical opinion over another if the Board provides an adequate statement of reasons or bases. Id.; see also 38 U.S.C. § 7104(d)(1). The Board finds that the November 2006 opinion of D.O.N (as well as the similarly worded opinion cited in an unrelated Board decision) is highly unpersuasive for two essential reasons: It is ultimately inconclusive with respect to the specific disability in this case, and it does not address the specifics of the in-service injury, but describes it in only the vaguest of terms. Regarding the inconclusive nature of the opinion, the assertion that a lumbar spine injury at a young age results in and promotes degeneration of the spinal structures as the years progress does not relate any specific current disability to the injury in service. While it sets out a general medical principal that may be applicable to this case, it does so in inherently general terms, and it attaches no particular likelihood that this Veteran's lumbar spine disability is related to the in-service injury noted in his service records. The CAVC has repeatedly and consistently rejected medical opinions raising only a possibility of medical nexus as being insufficient to establish nexus. See McLendon v. Nicholson, 20 Vet. App. 79, 85 (2000); Beausoleil v. Brown, 8 Vet. App. 459 (1996) (general and inconclusive statement about the possibility of a link between current disability and service injury is insufficient); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Regarding the specifics of the in-service injury, D.O.N. identified an "injury to the lumbar spine." This misrepresents what was recorded in the service treatment records. In fact, the injury was identified as muscle spasms and a sprain. There is no finding of an injury to the spine itself. This fact was deemed significant to the July 2009 VA examiner, as he found nothing in the orthopedic literature indicating that an isolated lumbar strain will cause degenerative disc disease in the lumbar spine. It is unclear what records were reviewed by D.O.N., however, even assuming he had the Veteran's service records for review, the important factor in a review of the claims file is what an examiner learns from the claims file for use in forming the expert opinion, and not just the reading of the file. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). Here, D.O.N.'s minimal discussion and mischaracterization of the in-service injury leads the Board to conclude that he did not have an accurate understanding of the nature of the in- service injury irrespective of whether or not he actually reviewed the service treatment records. This undercuts the probative value the Board places on the opinion. In contrast, the July 2009 VA opinion demonstrates an understanding of the nature and details of the Veteran's in- service injury, and of the findings at service separation, which were also not discussed by D.O.N. The VA opinion is stated conclusively, and a specific etiology is identified. Also supportive of the July 2009 opinion and persuasive to the Board is the history of the Veteran's assertions regarding his back injury. After service, the Veteran did not file a disability or pension claim with VA for almost 20 years. While inaction for many years regarding filing a claim is not necessarily indicative of the absence of symptomatology, when the Veteran filed his claim in November 1995, he did not assert that his lumbar spine disability was related to service. Rather, he asserted that cold injury residuals and hepatitis were related to service. The record demonstrates that he had a back disability at the time of the claim; however, his actions are inconsistent with an individual who believed that his back disability was related to service. Moreover, the Veteran was examined in July 1996 for pension purposes and he identified the date of onset of the back disability as 1991. The Veteran reported to a mental disorders examiner in July 1996 that, other than frostbite and hepatitis, he did not have any major problems in the service. He again described his back injury as when he fell off a ladder on the job in July 1991. His own statements provide the best evidence against his claim and the "medical opinion" that supports his claim is, a best, unclear, at worst, to be regarded with suspicion Beyond this, as noted above, the Veteran submitted a disability determination of the Social Security Administration (SSA) with his November 1995 claim. That decision dated in October 1995 recounted the history of the Veteran's various disabilities. It was noted that he injured his back in 1989 and again in July 1991. The in- service injury was not mentioned. Upon the denial of service connection for hepatitis and frostbite, the Veteran filed a notice of disagreement in September 1996, asserting that both conditions were related to service. Again, he did not mention a back disability. It is not until October 2005, 10 years after his initial claim for VA benefits, during which period the Veteran was in frequent contact with VA regarding other claims, and almost 30 years after service separation, that the Veteran first asserted that a back injury was related to service. There is no question that the Veteran injured his back in service playing basketball; however, his reports to healthcare providers and to VA prior to October 2005 show that he made a clear distinction between his cold injury residuals and hepatitis, which he believed were related to service, and his back disability, which he specifically and repeatedly asserted had post-service origins. In weighing the conflicting accounts provided by the Veteran, the point in time in which the statement was made is important. Because, prior to October 2005, the Veteran was seeking only medical evaluation of his back and other disabilities, and was not seeking service connection for a back disability, it seems likely that he would report events surrounding the back more carefully and accurately. Statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care. In contrast, when the Veteran thereafter presented his account, he was seeking VA benefits for the back disability. The Board is of course cognizant of possible self interest which any veteran has in promoting a claim for monetary benefits. The Board may properly consider the personal interest a claimant has in his or her own case, but the Board is not free to ignore his assertion as to any matter upon which he is competent to offer an opinion. See Pond v. West, 12 Vet. App. 341, 345 (1999); and see Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). There is no question that the Veteran is competent to relate events as he remembers them. Thus, his competency is not at issue with regard to recounting the events of service or after service. Rather, it is the accuracy of the Veteran's recent account which the Board finds is lacking. Simply put, the Board finds that the Veteran's actions and assertions made prior to the current claim more accurately reflect the onset and cause of his lumbar spine disability than his recent assertions that his lumbar spine disability began in service. The parties to the Joint Motion stipulated that, in its prior December 2007 decision, the Board erred when it relied on its own medical speculation that the in-service acute back problem had "resolved". The parties identified the November 2006 opinion from D.O.N, noting that the Veteran had several service-connected injuries and disability, including lumbar injury, and "[s]uch an injury to the lumbar spine at a fairly young age is likely to result in and promote degeneration of the spinal structures as the years progress." The Board notes that, since the December 2007 decision, the opinion evidence added to the record further bolsters the Board's finding that the Veteran's in-service back injury had "resolved" by the time he left service, and that a series of post-service work-related injuries were the cause of his current lumbar spine disability. As set out above, the opinion of D.O.N. is not conclusively stated and is otherwise given little probative weight. The Veteran has submitted several medical treatise articles generally attesting to the proposition that a previous episode of low back pain is the strongest risk factor for a new episode, and that the absence of symptoms does not indicate resolution of the injury. One of the articles notes that limping can, in some specific instances, cause back pain and aggravate pre-existing back pain. With regard to medical treatise evidence, the CAVC has held that a medical article or treatise can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discussed generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998). In this case, the medical text evidence submitted by the Veteran fails to demonstrate with any degree of certainty a relationship between the Veteran's lumbar spine disability and any service-connected disability or in-service injury or disease. The article on limping specifies that such a relationship exists only in "some specific instances." As discussed above, medical opinion that is not conclusively stated, but asserts only the possibility of a relationship, is not probative evidence, or evidence that tends to prove the question at hand. Notably, the treatise evidence submitted by the Veteran does not account for the significant evidence of post-service back injuries, which were found by several medical professionals to be the most likely cause of the Veteran's lumbar spine disability. For these reasons, the Board finds that the medical text evidence does not contain the specificity to constitute competent evidence of the claimed nexus in this case. While the Joint Motion was focused on the evidence pertinent to a direct service connection theory of etiology, and did not address the Board's prior determination that a lumbar spine disability is not proximately due to or a result of any service-connected disability, the Board notes that there is no medical opinion of record that purports to establish such a relationship. The Veteran's former attorney has asserted that the Veteran's service-connected cold injury residuals and Raynaud's disease were the proximate cause of his fall from a ladder in July 1991. The May 2007 VA opinion that it was "less than likely" that the Veteran's lumbar spine conditions were related to his cold injury residuals but were rather related to on-the-job injuries directly addresses this asserted theory of etiology. The examiner found that the Veteran's hands showed no sign of significant weakness or deformity that would support an assertion that cold injuries caused the fall from a ladder in 1991. The July 2009 VA examiner opined that there was no support in the orthopedic literature for degenerative disc disease being caused by residuals of a cold injury that occurred 20 or more years prior. The examiner found that the spine disability is more likely related to the on-the-job injuries. The medical opinion evidence simply does not support the purported secondary service connection theory of etiology. While the Veteran is competent to report his symptoms and the events surrounding the 1991 fall, he has provided no description of this event that would lead to the conclusion that it was caused by his cold injury residuals. The Board notes that Raynaud's disease was not diagnosed until 1997, well after the ladder fall. While cold injury residuals were diagnosed at the time of the fall, in the descriptions the Veteran gave to medical providers shortly after the 1991 injury, he did not attribute the fall to his cold injury residuals. Indeed, he reported in April 1992 that, prior to the injury, he had been involved in lifting weights and running. He reported in October 1992 that he was doing very well until July 8, 1991 when he was injured at work. This evidence undercuts the recent assertions of his former attorney that his cold injury symptoms caused the fall, and serves to bolster the finding of the May 2007 VA examiner that the Veteran's hands exhibited no strength deficits that would account for the fall. Finally, the Veteran's former attorney has asserted that all of the Veteran's disabilities are inextricably intertwined. It is unclear what, in fact, was intended by this assertion, other than that service connection should be granted for all claimed disabilities, notwithstanding the significant evidence against this claim, including prior statement from the Veteran himself. The Board simply notes that for service connection to be granted for any disability, the elements set out in detail above must be established. As the weight of the evidence is against the onset of a lumbar spine disability in service, is against chronic symptoms of arthritis in service or manifestation of arthritis to a compensable degree within a year of service separation, is against continuity of arthritis symptomatology after service, and is against any relationship between a current lumbar spine disability and service, or any service-connected disability, the Board finds that service connection for a lumbar spine disability is not warranted. In reaching the above findings of fact and conclusions of law, 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, 1 Vet. App. at 53-56. Duties to Notify and Assist As noted above, the appeal involves a remand by the Board for additional evidentiary development. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). While substantial compliance is required, strict compliance is not. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In this case, the RO substantially complied with the Board's May 2009 remand instructions by scheduling the Veteran for a VA examination, which was provided in September 2009. The examiner acknowledged a review of the claims file in conjunction with the examination. The examiner provided an opinion addressing whether it is at least as likely as not that the Veteran's spine disability is a result of or related to his military service. The examiner also opined as to whether it is at least as likely as not that the Veteran's lumbar spine disability is due to or associated with his service-connected cold injuries. The examiner provided a rationale for the opinions. The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The CAVC issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Veteran submitted his claim for service connection for a lumbar spine disability in October 2005. He was sent a letter in February 2006 which advised him of the information and evidence necessary to substantiate the claim. Since the letter was sent to the Veteran prior to the initial adjudication of the claim in April 2006, there exists no error in the timing of this notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). A January 2007 letter included notice of the evidence necessary to substantiate the claim on a secondary service connection basis. The timing deficiency with respect to this notice was cured by readjudication of the claim in May 2007. Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007). The Board notes that the Veteran has not been provided specific notice regarding disability ratings and effective dates. However, because the Board's decision herein denies the claim for service connection, no disability ratings or effective dates are being, or will be, assigned. Accordingly, there is no possibility of prejudice under the notice requirements of Dingess/Hartman. VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, records from the Social Security Administration, and the Veteran's written assertions and those of his attorneys. The Veteran asserted in July 2010 correspondence that he was told by telephone that not all of his service treatment records were found, "or maybe just not sent." According to the Veteran, these records include evidence of a disc bulge and that he was told to give it time and it would get better. The Board finds that the entire service treatment records were obtained and there is no indication that there are any missing records. If a VA employee informed the Veteran that his records were missing, this finding is not recorded in claims file. While the Veteran is competent to relate information provided to him, the Board finds that the normal findings on the service separation examination for the spine, as well as the specific medical opinions concerning this issue, are more persuasive than the Veteran's recent unsupported assertion that an apparently complete set of service treatment records is missing the very records that support in-service onset of the claimed disability. The Veteran's assertion as to missing records is not accurate, and his assertion that he was found to have a spinal disc abnormality in service is unpersuasive. See Pond v. West, 12 Vet. App. 341, 345 (1999); and see Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (the Board may properly consider the personal interest a claimant has in his or her own case, and such interest may affect the credibility of testimony). The Veteran was afforded a VA examination from which an opinion was rendered as to the etiology of the Veteran's lumbar spine disability. The July 2009 examination was adequate because it was performed by a medical professional based on a review of claims file, solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. The resulting diagnosis and opinion were accompanied by a rationale that was consistent with the record, and that demonstrated an understanding of the record. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The Board acknowledges the repeated assertions of the Veteran's previous attorney that the medical opinion evidence is inadequate on the issue of entitlement to service connection for a lumbar spine disability. The Veteran's previous attorney also requested that the Board should obtain a medical opinion regarding her assertion that, but for the service-connected cold injury residuals, the Veteran would not have fallen from a ladder in July 1991 and injured his back. The Board notes that the May 2007 VA examiner in fact provided an opinion on the question of secondary incurrence involving the on-the-job fall from a ladder, finding that the Veteran's hands showed no sign of significant weakness or deformity that would support this contention, and that it was less than likely that the Veteran's lumbar spine disability was related to his cold injury residuals. While the May 2007 opinion did not directly address the question of aggravation of the nonservice-connected lumbar spine disability by the service-connected cold injury residuals, the Board finds that, in the context of the assertions raised by the Veteran, the opinion adequately addresses aggravation. The Veteran and his attorney contended that the claimed secondary service connection etiology was based on the effect of the cold injury residuals on a specific incident - the 1991 ladder fall - and not on a gradual or ongoing process, such as an alteration in gait or posture. The May 2007 opinion specifically addressed this incident and contention and found that the cold injury residuals did not play any significant role in the fall from the ladder. As this specific incident was the only asserted basis for the secondary service connection theory, the Board finds that this opinion adequately addresses both causation and aggravation. The Veteran's former and current attorneys have made other rather nonspecific assertions of failure to obtain medical reports, failure to provide adequate examinations, and failure to obtain medical opinions that are supported by medical literature, or that consider all of the Veteran's disabilities as a whole, that our difficult to address in that they are highly generalized, notwithstanding the fact that this case has been ongoing for more than seven years. These assertions are repeated in numerous submissions; however, except for what has been addressed above, they provide no specific examples and do not typically identify the claim toward which they are directed. Further, they have provide limited information in support of this claim, other than a medical opinion that the Board views with great concern regarding its overall objectivity, for reasons cited above. The Board finds that, for the reasons discussed above, the records pertinent to this issue that were identified by the Veteran were obtained, and he was provided an adequate examination that addressed his specific contentions regarding the etiology of his lumbar spine disability. The duties under the VCAA have been met. ORDER Service connection for a lumbar spine disability is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs