Citation Nr: 1328763 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 08-33 512 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for neurocardiogenic syndrome and presyncope, to include as secondary to an anthrax vaccination. 2. Entitlement to service connection for obstructive sleep apnea, to include as secondary to neurocardiogenic syndrome and presyncope. 3. Entitlement to service connection for a low back disability. 4. Entitlement to service connection for a hip disability. REPRESENTATION Appellant represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD K. R. Fletcher, Counsel INTRODUCTION The Veteran had active service from December 1984 to April 1992. This matter was originally before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. These issues were previously before the Board in February 2011, at which time the Board denied the application to reopen the claim for service connection for neurocardiogenic syndrome and presyncope, and the claim for service connection for obstructive sleep apnea. The Board also remanded the issues of entitlement to service connection for back and hip disabilities. Thereafter, the Veteran appealed the Board's denial of his claims to the United States Court of Appeals for Veterans Claims (Court). In January 2012, the Court issued an order that granted a Joint Motion for Partial Remand (Joint Motion) filed by counsel for both parties, vacated the Board's February 2011 decision with respect to the issues of whether new and material evidence had been received to reopen a claim for service connection for neurocardiogenic syndrome and presyncope, and entitlement to service connection for obstructive sleep apnea, and remanded those matters to the Board for action in compliance with the Joint Motion. In August 2012, the Board found that new and material evidence had been received to reopen a claim for service connection for neurocardiogenic syndrome and presyncope. The Board remanded the underlying claim for service connection for neurocardiogenic syndrome and syncope and the claim for service connection for obstructive sleep apnea. In addition to the paper claims file, there is a Virtual VA (VVA) electronic claims file associated with the Veteran's claim. The documents in the VVA file are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. Neurocardiogenic syndrome and presyncope were not present in service or for many years thereafter, and are not shown to be etiologically related to service, to include any vaccinations received therein. 2. Sleep apnea was not present during service and is not etiologically related thereto, or to service-connected disability. 3. Any low back injury in service was acute and resolved with no residual disability at the time of separation; arthritis of the low back was not manifested in the first post-service year; and the Veteran's current low back disability is not etiologically related to her service. 4. Hip disability was not present in service or for many years thereafter, and is not shown to be etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for neurocardiogenic syndrome and presyncope are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for service connection for sleep apnea are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2012) 3. The criteria for service connection for a low back disability are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 4. The criteria for service connection for a hip disability are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 &Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Regarding the claims decided herein, the record reflects that the Veteran was mailed notice in October 2007 and April 2013, advising him of what the evidence must show and the respective duties of VA and the claimant in obtaining evidence, as well as the appropriate notice with respect to the disability-rating and effective-date elements of the claims. Although the Veteran was not provided complete notice for all his claims prior to their initial adjudication, the Board finds that there is no prejudice to him in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the Veteran's claims. See May 2013 Supplemental Statement of the Case. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claims would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). The Board also finds VA has complied with its duty to assist the Veteran in the development of his claims. In this regard, the Board notes that all available service treatment records (STRs), service personnel records and post-service treatment records were obtained. Neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate the claims; the Board is also unaware of any such evidence. Regarding the claimed neurocardiogenic syndrome and presyncope, low back disability and hip disability, the Veteran underwent the appropriate VA examinations in January 2013 to determine the etiology of his claimed disabilities. Review of the examination reports shows that the examiners reviewed the claims file and provided a complete rationale for the opinions provided, as directed by the February 2011 and August 2012 Board remands. The Board thus finds that there has been substantial compliance with its remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Regarding the claimed sleep apnea, the Board finds that no additional development for medical opinions or examinations is necessary. Specifically, there is no medical evidence suggesting that the claimed sleep apnea was present until many years after the Veteran's military service or suggesting that the claimed disability is etiologically related to service or service-connected disability. The Board recognizes that the threshold for whether a present disability may be related to service is a low one. McLendon v. Nicholson, 20 Vet. App. 79 (2006). However, under the circumstances of this case, the low threshold has not been met. Accordingly, the Board concludes that VA has complied with its duty to assist the Veteran. VA's duties to notify and assist are met. Accordingly, the Board will address the merits of the claims. II. Service Connection Law and Regulations Service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. 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 opposed to merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service (or during any applicable presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including cardiovascular disease and arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. See 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. If the condition at issue is not a "chronic disease" listed under 38 C.F.R. § 3.309(a), 38 C.F.R. § 3.303(b) does not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection also may be granted for disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both 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"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). That notwithstanding, a veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza, supra. The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. III. Factual Background and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although there is an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. A. Neurocardiogenic Syndrome and Presyncope The Veteran maintains that he was exposed to anthrax by pre-deployment vaccinations. He further maintains that his body reacted to the vaccination as manifested by neurocardiogenic syndrome and presyncope. See June 2007 statement from the Veteran. The STRs do not include any reference to neurocardiogenic syndrome or presyncope. The STRs are negative for any indication of an anthrax vaccination in service or any reactions thereto; an immunization record form documenting vaccinations received between 1984 and 1992 fails to reflect that an anthrax vaccine was ever administered to the Veteran. Upon periodic examination of June 1990, both cardiovascular and neurological clinical evaluations were normal. There is no evidence that a separation evaluation was conducted. The Veteran underwent a VA examination in April 1992. The report of this examination does not show that the Veteran mentioned having an anthrax vaccine in service or any residuals thereof. No complaints or findings related to neurocardiogenic syndrome or presyncope were noted. Private medical records from a hospital in Ohio show that the Veteran was treated in August 2000 for symptoms of syncope, diagnosed as vasomotor syncope. His past medical history was recorded and was negative for mention of an anthrax vaccination in service. Private hospitalization records dated in June 2003 reflect that the Veteran was hospitalized for treatment of neurocardiogenic syncope. Records related to that hospitalization reflect that this condition had its onset in 1998, at which time the Veteran was having presyncopal and syncopal events manifested by weakness, light-headedness, nausea, and diaphoresis. He was treated at a private hospital in Ohio. Thereafter, his condition was controlled until about May 2003 when the Veteran had an episode of increased heart rate and presyncope while driving. The June 2003 hospitalization records do not include any mention any history of an anthrax vaccination. Sinus arrest, possibly representing sleep apnea, obesity and mild concentric left ventricular hypertrophy and left arterial enlargement were also diagnosed. A June 2003 letter from Dr. H, the Veteran's private cardiologist, includes the Veteran's report of experiencing recurrent episodes of syncope and near syncope since 2003, following a period of extreme emotional stress. The Veteran underwent a clinical examination, after which the cardiologist concluded that he was most likely suffering from periods of severe neurocardiogenic syncope. A November 2003 VA record cardiology note shows that the Veteran had a three-year history of recurrent syncope and treatment using prescription medication. After a clinical assessment, the examiner concluded that the Veteran suffered from drug refractory vasovagal syndrome and the implantation of a pacemaker was recommended. Treatment records dated in April, June and July of 2004 include the Veteran's report of receiving an anthrax vaccine in the early 1990's. The April 2004 VA treatment record shows that the Veteran was diagnosed with neurocardiac syncope, chronic intermittent muscle cramps, and history of anthrax vaccination in 1990. During a June 2004 neurology consultation, the Veteran reported that his first syncopal episode occurred at the age of thirty-six. Treatment records dated in March 2005 and January 2005 include the Veteran's report of neurocardiogenic syncope since 2000. In a 2006 decision, the Social Security Administration (SSA) determined that the Veteran was disabled from May 2003 due to a primary diagnosis of neurocardiogenic syncope. In a statement provided by the Veteran's representative, it was urged that VA visit a website reportedly relating to a possible connection between anthrax vaccines and neurocardiogenic syncope. Also added to the file was the story of a Persian Gulf War veteran who had been diagnosed with neurocardiogenic syncope and who had provided testimony relating to the anthrax vaccine. Private and VA records dated in 2008 and 2012 reflect that the Veteran continued to be treated for neurocardiogenic syncope. A January 2013 VA DBQ examination report notes that the Veteran reported a history of anthrax vaccination in 1991 and presyncope since 1998. After examining the Veteran and reviewing the claims file, the examiner opined that the Veteran's neurocardiogenic syndrome and presyncope are not likely related to his military service, to include any anthrax vaccinations received therein. The examiner noted that the Veteran's STRs and treatment records dated shortly after discharge are negative for neurocardiogenic syndrome and presyncope. The examiner also noted that the medical evidence shows (and the Veteran agrees) that his heart symptoms began several years after his discharge from service (in 1998 according to the Veteran and 2000 according to the medical evidence). Moreover, no medical literature supports a cause, effect relationship between his claimed heart disability and vaccinations. The examiner noted several other known causes for neurocardiogenic syndrome and presyncope, including stress, dehydration, bleeding and pain. After reviewing the evidence of record, the Board finds that the preponderance of the evidence is against the claim. The record does not contain any competent evidence that neurocardiogenic syndrome or presyncope was present in service or manifested within a year of the Veteran's discharge; in fact, (as noted above) the Veteran himself has stated that the onset of this disability was in 1998, six years after service. Consequently, service connection for such disability on the basis that it was manifested in service or within the first year after service is not warranted. The Veteran may still establish service connection for neurocardiogenic syndrome and presyncope by competent and probative evidence showing that such disability is somehow related to service. However, the medical evidence of record does not show or suggest that currently present neurocardiogenic syndrome and presyncope is (or might be) etiologically related to service (to include any vaccines received therein). In fact, the January 2013 VA DBQ examiner stated the Veteran's neurocardiogenic syndrome and presyncope is less likely than not (less than 50 percent probability) to have been incurred in or caused by his military service, to include any vaccination received therein. The examiner provided reasons and bases for the opinion, as noted above. There is no medical evidence to the contrary. Moreover, the Board concludes that the medical evidence is of greater probative value than the Veteran's lay allegations. Considering the absence of competent medical evidence of disability until six after service, the preponderance of the evidence is against service connection for the claimed disability. The Veteran himself believes that his disability was caused by an anthrax vaccination received in service. However, medical expertise is required to answer the question of whether the Veteran's heart disability is related to service, to include a vaccination received therein. The Veteran's lay opinion concerning this matter requiring medical expertise is of no probative value. Jandreau, supra. Regarding the website (medical treatise) evidence referenced by the Veteran's representative, the Court 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). The medical treatise, [textbook, or article] must provide more than speculative, generic statements not relevant to the appellant's claim but must discuss generic relationships with a degree of certainty for the facts of a specific case. Wallin v. West, 11 Vet. App. 509, 514 (1998). In this case, however, the internet article evidence was referenced by the Veteran's representative and was not accompanied by the medical opinion of a medical professional. In addition, the article does not provide statements for the facts of the Veteran's specific case. For these reasons, the Board finds that the article does not contain the specificity to constitute competent evidence of the claimed medical nexus. See Sacks, 11 Vet. App. at 317; see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996). The preponderance of the evidence is against this claim; hence, it must be denied. B. Sleep Apnea The Veteran maintains that his sleep apnea was caused by neurocardiogenic syndrome and presyncope. See June 2007 statement from the Veteran. The STRs, to include a periodic examination report of June 1990, are entirely negative for any complaints, findings or diagnosis relating to a sleep disorder. There is no evidence that a separation examination was conducted. A VA examination report of April 1992, fails to mention sleep impairment or sleep apnea. Private medical records of June 2003 reflect that the Veteran was hospitalized for treatment of neurocardiogenic syncope. Sinus arrest, possibly representing sleep apnea, was also diagnosed at that time. An October 2004 VA pulmonary report indicates that the Veteran underwent polysomnography which revealed severe obstructive sleep apnea REM associated with significant oxygen desaturation. The assessment indicated that decreased sleep efficiency and abnormal sleep architecture might be related to sleep in a lab environment, medications, medical illness or underlying anxiety or mood disorder. A 2006 SSA decision includes reference to sleep apnea being diagnosed. An October 2007 nocturnal polysomnography study revealed obstructive sleep apnea. Private and VA records dated from 2008 to 2012 reference that the Veteran continued to use a CPAP at home for obstructive sleep apnea. After reviewing the evidence of record, the Board finds that the preponderance of the evidence is against the claim. The record does not contain any competent evidence that sleep apnea was present in service or for many years thereafter. As noted above, the Veteran made no complaints in this regard until 2003, more than 10 years after service. Consequently, service connection for such disability on the basis that it was manifested in service is not warranted. The Veteran may still establish service connection for sleep apnea by competent and probative evidence showing that such disability is somehow related to service. However, the medical evidence of record does not show or suggest that currently present sleep apnea is etiologically related to service. The Veteran has not alleged this to be the case either. With regard to a secondary service connection theory of entitlement, inasmuch as neurocardiogenic syndrome and presyncope are not service connected, a threshold legal requirement for establishing service connection for sleep apnea as secondary to such disability, as alleged, is not met. In other words, it is not shown that the primary disability (neurocardiogenic syndrome and presyncope) alleged to have caused or aggravated the sleep apnea for which secondary service connection is sought is service connected. Accordingly, the claim of service connection for sleep apnea as secondary to neurocardiogenic syndrome and presyncope must be denied as lacking legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The preponderance of the evidence is against this claim; hence, it must be denied. C. Low Back The Veteran maintains that he injured his back while picking up camouflage netting to drape over vehicles while serving in Germany in 1987 and 1988, for which he received medical treatment. He further noted that in 1990 during service, he had undergone an MRI in-service for back injuries, but before the results could be screened, he was placed on deployment status. See June 2007 statement from the Veteran. STRs show that the Veteran was seen in January 1989 with complaints of a three-month history of low back pain; the assessment was low back strain. Upon periodic examination of June 1990, clinical evaluation of the spine was normal and there was no notation by the Veteran of any back problems, although he had identified several other medical problems. It does not appear that a separation evaluation was conducted. An April 1992 VA examination report notes the Veteran's complaints of a two-year history of low back pain. Examination of the lumbar spine revealed tenderness in the lumbosacral spine without deformity, tremors, twitching or muscle atrophy. X-ray studies revealed no evidence of bony abnormality, and showed congenital lack of ossification of the lamina of S1. Low backache was diagnosed. A January 2005 VA treatment record reveals that the Veteran failed to report having any low back problems; on examination, range of motion of the back was full. An April 2006 VA treatment record reflects that the Veteran failed to complain of any low back problems and denied having joint stiffness or swelling, muscle pain, or cramps. Records associated with a 2006 SSA disability decision are negative for complaints, treatment, or diagnosis relating to the low back. A December 2006 private radiology report shows findings of narrowing of the L5-S1 disc space. The Veteran underwent a private medical evaluation in July 2007, primarily for sleep apnea. At that time, examination of the back revealed no deformities and no tenderness. VA and private treatment records dated from 2008 to 2011 note the Veteran's ongoing complaints of and treatment for low back pain. Imagining studies obtained in 2011 revealed multilevel degenerative disc disease and degenerative joint disease of the lumbosacral spine. A January 2013 VA DBQ examination report notes the Veteran's report of injuring his back as a result of heavy lifting in 1989 or 1990. He stated that although the pain improved with treatment, it never really went away. The Veteran also reported that he was in a car accident in 2000; this accident exacerbated his back problems. After examining the Veteran and reviewing the claims file, the examiner noted a diagnosis of multilevel degenerative disc disease and degenerative joint disease of the lumbosacral spine, as confirmed by imaging studies in March and April 2011. The examiner opined that the Veteran's current back disability is not related to his active duty service, to include the complaints of back pain noted in 1989. In this regard, the examiner noted that the Veteran was diagnosed with low back strain, "a transient condition, known to resolve with treatment." The examiner further noted that subsequent objective examination findings and X-ray studies obtained in April 1992 were normal. The examiner further noted that the Veteran's low back arthritis was not manifested during his first post-service year. It was the examiner's opinion that the Veteran's multilevel degenerative disc disease and degenerative joint disease are part of the normal aging process. After reviewing the evidence, the Board finds that the preponderance of the evidence is against the claim. Upon review of the evidence, the Board notes that although the Veteran was seen for complaints specific to the low back on one occasion (January 1989) during active duty, no residual chronic low back disability was noted in subsequent STRs. Moreover, X-ray studies obtained in April 1992 were normal. Consequently, service connection for chronic low back disability on the basis that it was manifested in service or within the first year after service is not warranted. The Veteran may still establish service connection for low back disability by competent and probative evidence showing that such disability is somehow related to service. However, the medical evidence of record does not show or suggest that currently present low back disability is (or might be) etiologically related to service (to include complaints of pain noted in 1989). In fact, the January 2013 VA DBQ examiner stated the Veteran's current low back disability is less likely than not (less than 50 percent probability) to have been incurred in or caused by his military service, to include the diagnosis of low back strain noted in January 1989. The examiner provided reasons and bases for the opinion, as noted above. There is no medical evidence to the contrary. Moreover, the Board concludes that the medical evidence is of greater probative value than the Veteran's lay allegations. The Veteran maintains that his back pain never really went away after service; however, his post-service treatment records note that he denied such problems during many examinations, as noted above. The Veteran himself believes that his disability was caused by an injury in service. However, medical expertise is required to answer the question of whether the Veteran's current low back disability is related to service, to complaints of back pain noted therein. The Veteran's lay opinion concerning this matter requiring medical expertise is of no probative value. Jandreau, supra. The Board has also considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. D. Hip The Veteran maintains that he sustained a hip injury while picking up camouflage netting to drape over vehicles while serving in Germany in 1987 and 1988, for which he received medical treatment. See June 2007 statement from the Veteran. STRs include a periodic examination report of June 1990, wherein the Veteran provided a written statement to the effect that his left hip was bothering him. No examination findings or diagnosis pertinent to the hip were noted. It does not appear that a separation evaluation was conducted. A September 2008 VA treatment record notes that the Veteran had arthritis of the hips. The examiner noted that X-rays studies had been conducted by a private examiner. A June 2009 VA problem list for the Veteran included hip pain. Imaging studies obtained in April 2011 showed mild osteoarthritis of both hips. A January 2013 VA DBQ examination report notes the Veteran's report of sustaining a bilateral hip injury as a result of heavy lifting in 1989 or 1990. He stated that although the pain (left greater than right) improved with treatment, it never really went away. The Veteran also reported that he did not seek any medical treatment until about 2008 or 2009, when he was diagnosed with arthritis. After examining the Veteran and reviewing the claims file, the examiner noted a diagnosis of mild osteoarthritis of both hips, as confirmed by April 2011 imagining studies. The examiner opined that the Veteran's current bilateral hip disability is not related to his active duty service, to include the hip complaints noted in 1990. In this regard, the examiner noted examination in 1990 was normal. In fact, no hip disability was ever diagnosed during the Veteran's active duty service. The examiner further noted that the Veteran's bilateral hip arthritis was not manifested during his first post-service year. It was the examiner's opinion that the Veteran's bilateral hip arthritis is part of the normal aging process. After reviewing the evidence, the Board finds that the preponderance of the evidence is against the claim. Upon review of the evidence, the Board notes that although the Veteran was seen for complaints specific to the hips on one occasion (June 1990) during active duty, examination at that time revealed no hip disability. Moreover, no chronic hip disability was noted in subsequent STRs. Arthritis was not diagnosed during the first post-service year. Consequently, service connection for a hip disability on the basis that it was manifested in service or within the first year after service is not warranted. The Veteran may still establish service connection for a hip disability by competent and probative evidence showing that such disability is somehow related to service. However, the medical evidence of record does not show or suggest that currently present hip disability is (or might be) etiologically related to service (to include complaints noted in 1990). In fact, the January 2013 VA DBQ examiner stated the Veteran's current bilateral hip disability is less likely than not (less than 50 percent probability) to have been incurred in or caused by his military service, to include the complaints noted in June 1990. The examiner provided reasons and bases for the opinion, as noted above. There is no medical evidence to the contrary. Moreover, the Board concludes that the medical evidence is of greater probative value than the Veteran's lay allegations. The Veteran himself believes that his hip disability was caused by an injury in service. However, medical expertise is required to answer the question of whether the Veteran's current hip disability is related to service, to complaints noted therein. The Veteran's lay opinion concerning this matter requiring medical expertise is of no probative value. Jandreau, supra. The Board has also considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. [Continued on Next Page] ORDER Service connection for neurocardiogenic syndrome and presyncope is denied. Service connection for obstructive sleep apnea is denied. Service connection for a low back disability is denied. Service connection for a back disability is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs