Citation Nr: 1329769 Decision Date: 09/17/13 Archive Date: 09/25/13 DOCKET NO. 10-10 726 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for C5-6 posttraumatic cervical spondylosis and degenerative disc disease (DDD). 2. Entitlement to service connection for a low back condition. ATTORNEY FOR THE BOARD Laura E. Collins, Associate Counsel INTRODUCTION The Veteran served on active duty from May 2002 through May 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by the RO in April 2008 that denied service connection for low back pain and granted service connection for C5-6 spondylosis and DDD, assigning a 10 percent initial disability rating. In November 2012, the Board remanded the case for additional development. The case now returns for further appellate review. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's C5-6 spondylosis and DDD has manifested with forward flexion of the cervical spine greater than 30 degrees, combined range of motion of the cervical spine greater than 170 degrees, and without ankylosis or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 2. The most probative evidence indicates that the Veteran's low back condition is not related to service. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for C5-6 spondylosis and DDD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2012). 2. The requirements for establishing service connection for a low back condition have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 The Veteran's claim of entitlement to a higher initial rating for C5-6 spondylosis and DDD arises from his disagreement with the initial evaluation following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). As to the Veteran's claim of entitlement to service connection for a low back condition, the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this case, a letter dated in February 2007, sent prior to the decision on appeal, provided notice regarding what information and evidence is needed to substantiate his claim for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The same letter advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records (STRs), service personnel records, VA treatment records, private treatment records, VA examination reports, and lay statements. The Board also notes that actions requested in the prior remands have been undertaken. Indeed, VA treatment records from January 2009 to January 2013 were obtained and associated with the electronic claims file, a January 2013 letter was issued to the Veteran requesting information concerning providers who had treated him for his neck and back since October 2009, and a VA examination was conducted and opinion obtained. Accordingly, the Board finds that there has been substantial compliance with the prior remand directives and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). As discussed above, the Veteran was notified and aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was provided with a meaningful opportunity to participate in the claims process and has done so by providing evidence and argument. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Higher Rating Claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2012); see also 38 C.F.R. §§ 4.45, 4.59 (2012). Recently, the United States Court of Appeals for Veterans Claims clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. at 592. Spinal disabilities are generally rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula), whichever method results in the higher evaluation when all disabilities are combined under § 4.25. 38 C.F.R. § 4.71a, The Spine, Note (6) (2012). Under the General Rating Formula, the following evaluations are to be assigned for spinal disabilities with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. A 10 percent disability rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion (ROM) of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation will be assigned for a spine disability where there is forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, combined ROM of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent evaluation is warranted where there is forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent evaluation is warranted for unfavorable ankylosis of the entire cervical spine. Under the General Rating Formula, any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.71a, The Spine, Note (1) (2012). For VA compensation purposes, normal forward flexion of the cervical spine is 0 to 45 degrees, extension is 0 to 45 degrees, left and right lateral flexion are 0 to 45 degrees, and left and right lateral rotation are 0 to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. at Note (2); see also 38 C.F.R. § 4.71a, Plate V. Under Diagnostic Code 5243, intervertebral disc syndrome is to be evaluated either under the General Rating Formula or under the IVDS Formula, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a, Diagnostic Code 5243 and Note. Under the IVDS Formula, a 10 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A rating of 20 percent is warranted where there are incapacitating episodes with a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A rating of 40 percent is warranted for incapacitating episodes with a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A maximum rating of 60 percent is warranted for incapacitating episodes with a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. For these purposes, an incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The evidence of record contains several measurements of the Veteran's cervical spine range of motion (ROM), none of which meet the criteria for an evaluation in excess of 10 percent. Service treatment records contain many treatment records for neck pain and cervicalgia dated after a December 2003 motor vehicle accident (MVA), and almost all of which show full or normal ROM for the cervical spine. The exception is a November 2004 service treatment record that shows unspecified decreased ROM of the cervical spine due to pain. A private examination report dated January 2005 (during active service) showed 45 degrees of flexion/extension, 45 degrees lateral flexion bilaterally, 80 degrees rotation to the right and 60 degrees to the left passively, and 80 degrees rotation in both directions actively. These measurements result in a combined ROM of the cervical spine of 320 degrees on passive motion and 340 degrees on active motion. The April 2007 VA examination reported noted nonspecific "limitation in movements of the neck in flexion, extension and rotation." The July 2008 VA spine examiner measured, on active and passive motion: 45 degrees of flexion with pain at 35 degrees; 40 degrees extension with pain at 40 degrees; 40 degrees right lateral flexion with pain at 35 degrees; 45 degrees left lateral flexion with pain at 40 degrees; 50 degrees rotation with pain at 50 degrees bilaterally. These measurements result in a combined ROM of the cervical spine of 270 degrees, and 250 degrees without pain. An October 2008 VA treatment record showed full cervical spine ROM. The January 2013 VA cervical spine examiner measured 45 degrees of flexion; 45 degrees extension; 45 degrees lateral flexion bilaterally; 80 degrees bilateral rotation. No measurements had objective evidence of painful motion. These measurements result in a combined ROM of the cervical spine of 340 degrees. Thus, at worst, the Veteran's ROM was limited to forward flexion to 45 degrees with pain beginning at 35 degrees, extension to 40 degrees, right lateral flexion to 40 degrees with pain at 35 degrees, left lateral flexion to 45 degrees with pain at 40 degrees, and lateral rotation of 50 degrees bilaterally. The combined ROM is 270 degrees, (250 degrees considering pain). Thus, even considering painful motion, at no time was his forward flexion of the cervical spine limited to 30 degrees or less, or combined ROM of the cervical spine limited to 170 degrees or less. The Board has also considered functional loss pursuant to DeLuca, supra and the provisions of 38 C.F.R. § 4.40, 4.45, and 4.59. The January 2005 private medical examiner reported no effect on joint ROM due to pain, weakness, fatigue, or incoordination following repetitive use or flare-ups. He also observed no swelling, effusion, tenderness, muscle spasm, joint laxity, or muscle atrophy. The July 2008 VA examiner noted pain, but no additional loss of motion, after repetitive use for every cervical spine ROM. Effects on activities of daily living were mild effects on exercise, sports, recreation, bathing, and dressing. In his January 2010 substantive appeal, the Veteran stated that his cervical spine disability hindered him from lifting heavy objects. At the January 2013 VA examination, the Veteran denied that the function of his cervical spine was impacted by flare-ups. Additionally, the 2013 examiner found that there was no additional pain, limitation of ROM, or functional loss after repetition. As the evidence does not reflect the Veteran's ROM is limited to 30 degrees or less, even considering pain and functional impairment, an initial rating in excess of 10 percent is therefore not warranted under ROM criteria. Additionally, while a 20 percent rating could also be assigned due to muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, such is not shown by the medical evidence of record. The January 2013 VA examiner specifically denied findings of any localized tenderness to pain or palpation, guarding or muscle spasm, muscle atrophy, and abnormal gait or spinal contour. There is no positive evidence of these factors in the record. Finally, the evidence does not reflect ankylosis. For the reasons set forth above, the Board finds that the competent and probative evidence of record is against a higher rating for the Veteran's cervical spine disability under the General Rating Formula. In addition, the record does not reflect and the Veteran does not contend that he has suffered from incapacitating episodes of disc disease requiring bed rest prescribed by a physician and treatment by a physician. Thus, the provisions of the IVDS Formula would not result in a higher rating for the Veteran's cervical spine disability. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Board has also considered whether a separate rating is warranted for an associated neurological disorder. An October 2004 service treatment record states that the Veteran had no radiculopathy from his cervical condition. The Veteran made subjective complaints of pain radiating from his neck to his right upper extremity at his April 2007 VA neurological examination. The 2007 VA examiner noted no objective evidence of radiculopathy and recommended an electromyogram (EMG) of the upper extremities to evaluate radiculopathy objectively. In April 2008, EMG and nerve conduction (NVC) tests were conducted. The tests showed no evidence of right cervical radiculopathy, or medial or ulnar neuropathy. The April 2008 VA neurological examiner stated that these tests showed no objective signs of cervical radiculopathy. At his January 2013 VA cervical spine examination, the Veteran denied radiation of pain down his arms or hands. He had occasional pain in his neck, for which he took ibuprofen. Objective reflex, muscle strength, and sensory testing were all normal. The 2013 VA examiner found that the Veteran had no radicular pain or any other signs or symptoms due to radiculopathy. While the Veteran complained of subjective symptoms of radicular pain in 2007 and 2008, he denied these symptoms in 2013. Moreover, in light of the EMG and NVC tests and VA examiner opinions, there is no objective finding to support a separate rating for radiculopathy. Finally, the 2013 VA examiner specifically noted that there were no other neurological abnormalities related to the Veteran's cervical spine condition, including bladder or bowel problems. There is no evidence to the contrary. In sum, to the extent the Veteran has at times reported that his neck pain radiates, such is contemplated in the General Rating Formula, which specifically states that the evaluations are to be assigned for spinal disabilities with or without symptoms such as pain (whether or not it radiates). Thus, as the objective evidence fails to establish a separately compensable neurologic disability, the Veteran is not entitled to any separate evaluations for neurologic abnormalities. See 38 C.F.R. § 4.124a. The Board concludes that the medical findings on examination are of greater probative value than the Veteran's allegations regarding the severity of his cervical spine disability. Accordingly, the Board finds that the preponderance of the evidence is against the claim for a rating in excess of 10 percent. The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria, with consideration of 38 C.F.R. §§ 4.40, 4.45 and 4.59, reasonably describe the Veteran's disability level and symptomatology and provide for additional or more severe symptoms than currently shown by the evidence. The evaluation presently assigned takes into account his subjective complaints, the objective findings, and the functional impairment resulting from his disability. The Board has also considered his subjective complaints of radicular pain, but determined that with no objective findings to support them, a separate rating is not warranted. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. As a final matter, the Board notes that the July 2008 VA spine examiner stated the Veteran was employed full time in home health care and had lost less than one week of work in the last 12 months due to this disability, a VA psychiatric examiner noted in October 2010 that he worked about 58 hours per week as a home health aide, and the 2013 VA examiner found that his cervical spine condition did not impact the Veteran's ability to work. Accordingly, a claim for unemployability is not raised by the record, and no action pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009) is required. III. Service Connection Claim The Veteran seeks service connection for a low back condition as due to an injury sustained in active service, and contends that intermittent low back pain has continued since service. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b) (2012). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, 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, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. When there is an approximate balance of evidence for and against the issue, all reasonable doubt will be resolved in the Veteran's favor. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As noted above, the Board has reviewed all the evidence in the record. The Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. Gonzales; Timberlake. The earliest evidence of low back pain is a service treatment record dated May 2003 that shows a complaint of right-side low back pain that had been ongoing for five weeks. The Veteran was diagnosed with lumbar musculoskeletal spasm. Service treatment records also show that he was involved in an MVA in December 2003 when his vehicle rolled. In March 2004, while being seen for neck pain following the MVA, he denied back problems. In January 2005, while he was still in active service, the Veteran reported to a general medical examiner that his low back pain began in June 2003 but he could not identify a specific injury. He described the pain as intermittent and not affecting activities of daily living. He had not sought treatment for it. On physical examination, the examiner noted normal ROM of the lumbar spine, normal gait, and, on repetition, no effect on joint ROM due to pain, weakness, fatigue, or incoordination. He diagnosed non-specific low back pain, specifically noting that it was non-limiting and had no radicular signs. An x-ray of the lumbar spine taken in January 2006 showed a normal lumbosacral spine. VA treatment records show that in August 2006, one month after separating from service, the Veteran complained of back and neck pain ever since a trauma three years prior. In February 2007 he reported low back pain, but an x-ray of the lumbar spine was unremarkable and he was diagnosed with normal lumbar spine. The Veteran reported to the April 2007 VA neurological examiner that prior to the MVA he had occasional low back pain and discomfort and since the MVA he continued to experience the same occasional low back pain with no radicular component. In his descriptions of the MVA, he only described only neck and head pain resulting from that event. In January 2008 an MRI of the lumbar spine was conducted based on a clinical indications of the MVA in 2003 and low back pain. The MRI showed a small rudimentary disc at S1-2, and a desiccated L5-S1. It was otherwise unremarkable. October 2008 VA treatment records show that the Veteran was involved in another MVA where his vehicle was struck from behind. He complained of constant upper and lower back pain and was diagnosed with "musculoskeletal pain - probable muscle spasm after MVA." A September 2009 VA treatment record shows complaint of low back pain at a 7/10 intensity, exacerbated by forward flexion and standing but improved by ibuprofen. The physician diagnosed "back pain." The Veteran reported to the January 2013 VA thoracolumbar spine examiner that his low back pain began in 2003 after his MVA. His current pain was intermittent without a radicular component and he used ibuprofen for relief. On physical examination, ROM was normal without functional loss or impairment on repetition. The Veteran had mild muscle tenderness to palpation, without guarding or muscle spasm. Based on the imaging studies of record, there was no documented arthritis or vertebral fracture. The examiner found that there were no other significant diagnostic test findings. Based on his examination and thorough record review, the 2013 VA examiner diagnosed lumbar strain, without radiculopathy, intervertebral disc syndrome, or other neurologic abnormalities of the thoracolumbar spine. He opined that the current lumbar strain was less likely than not a result of active service, including the back complaints noted in the service treatment records. He reasoned that, following the documented lumbar complaints in service, the Veteran denied back problems. "His low back pain had evidently resolved." Further, the 2007 x-ray showed a normal lumbar spine. The 2013 VA examiner reviewed the claims file, including lay statements, examined the Veteran, and provided an adequate rationale for his opinion. The Board therefore finds this medical opinion is adequate and highly probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Additionally, while the Veteran contends that his back pain is related to his military service, there is no indication that he has specialized training in diagnosing back disorders or determining their etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis of back disorders requires medical testing to identify, and back disabilities can have many different causes, thereby requiring medical expertise to determine the etiology. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to his current back disorder is a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's own opinion regarding the diagnosis and etiology of his current back complaints is not competent medical evidence. The Board accords significantly more weight to the VA examiner's findings and opinion than to the Veteran's lay assertions as to the presence of a current back disability and its relationship to service. There is no competent medical opinion to the contrary. Accordingly, the Board finds the preponderance of the evidence is against the claim and service connection for a low back condition is denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. ORDER An initial rating in excess of 10 percent C5-6 spondylosis and DDD is denied. Service connection for a low back condition is denied. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs