Citation Nr: 1330702 Decision Date: 09/24/13 Archive Date: 09/30/13 DOCKET NO. 07-26 905 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a back disability, on a direct basis and as secondary to a service-connected disability. (The issue of entitlement to an initial disability rating in excess of 20 percent for tendonitis of the right ankle will be addressed in a separate decision). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.R. Bryant, Counsel INTRODUCTION The Veteran served on active duty from September 1972 to June 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating actions of the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. In May 2008, the Veteran testified at a hearing conducted at the RO before the undersigned Veterans Law Judge. A copy of the transcript has been associated with the claims file. [The Veteran has since relocated to Florida, and her claims file has been transferred to the RO in St. Petersburg.] In March 2009, March 2010, and in April 2013, the Board remanded the appeal to the RO via the Appeals Management Center (AMC) in Washington, DC, for further evidentiary development and adjudicative action. After completing the development requested most recently, the AMC continued to deny the claim (as reflected in a May 2013 supplemental statement of the case (SSOC)), and returned this matter to the Board for further appellate consideration. The Board has reviewed both the Veteran's physical claims file and the record maintained in the Virtual VA paperless claims processing system to ensure complete consideration of all the evidence. FINDINGS OF FACT 1. The Veteran failed to report for scheduled VA examination in May 2013 without good cause. Her failure to cooperate with the requested VA examination served only to deprive the Board of critical, clarifying medical evidence which might have helped establish her claim. 2. A chronic back disability, diagnosed as degenerative joint disease and/or degenerative disc disease, was not present in service and did not manifest to a compensable degree within one year of the Veteran's discharge from service-or, indeed, until many years thereafter. 3. As a result of the Veteran's failure to report for VA examination as directed in the Board's April 2013 remand, there is no competent medical, nor competent and credible lay, evidence that any diagnosed back disability is causally or etiologically related to service in any way or to any service-connected disability. CONCLUSION OF LAW A back disability was not incurred in or aggravated by service, and degenerative joint and/or disc disease may not be presumed to have been incurred in service and is not proximately due to or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307(a)(3), 3.309(a), 3.310, 3.655 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist Before addressing the merits of the right hip issue on appeal, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor her representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letters dated in June 2003, December 2003, and October 2005, of VA's duty to assist her in substantiating her claim under the VCAA, and the effect of this duty upon her claim. Although these initial letters did not comply with all dictates of Dingess, because service connection is being denied for the claimed disability, any question as to the appropriate disability rating or effective date ultimately is moot. Thus, even non receipt of notice concerning these downstream elements of this claim is, at most, nonprejudicial, i.e., harmless error. 38 C.F.R. § 20.1102. Meanwhile, a letter dated in May 2006 informed the Veteran of how disability ratings and effective dates are assigned. Dingess, 19 Vet. App. at 484. Together, these letters addressed all notice elements, nothing more was required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). [The timing defect of the May 2006 correspondence was cured by the RO's subsequent readjudication of the appeal and issuance of a statement of the case in May 2007.] The Board also finds that VA has satisfied its duty to assist the Veteran in the development of the service connection claim adjudicated herein. The Board has reviewed both the Veteran's physical claims file and the file on the Virtual VA electronic file system, to ensure a total review of the available evidence. Pertinent in-service and post-service treatment reports are of record. The Veteran has availed herself of the opportunity to submit relevant documents and argument in support of her claim as indicated by the five volumes of evidence already obtained. She has also submitted personal statements, representative argument, and provided testimony at the 2008 Board hearing. Following review of the extensive record, the Board finds that there is no additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The Board is also satisfied that the AMC has substantially complied with its most recent April 2013 remand directives as they pertain to the service connection matter decided herein. Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). As instructed by the Board, the AMC/RO arranged for the Veteran to undergo VA examination for additional medical comment concerning the etiology of her previously diagnosed lumbar degenerative joint disease and degenerative disc disease, to include whether they were due to service or were secondary to her service-connected right knee and ankle disabilities. However, the Veteran failed to appear for it and did not provide a justification for her failure to report, or otherwise indicate a willingness to appear for examination. Individuals for whom an examination has been scheduled are required to report for the examination. See 38 C.F.R. § 3.326(a). When entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination, and a claimant, without good cause fails to report for such examination, or reexamination action in accordance with this section shall be taken. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination was scheduled in conjunction with any other original claim, a reopened claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied. 38 C.F.R. § 3.655. There is no indication that the Veteran did not receive notice of the VA examination, and neither she nor her representative has requested that the examination be rescheduled. While VA has a duty to assist the Veteran in the development of her claim, she has a duty to cooperate with VA. See Wood v. Derwinksi, 1 Vet. App. 190 (1991). Given the RO actions and the Veteran's choice not to submit to VA examination, the Board finds that VA has no remaining duty under the VCAA with regard to a medical examination and opinion in conjunction with this claim. The appeal will be based on the evidence of record. Thus, the Board finds that VA has satisfied its duty to assist the Veteran in apprising her as to the evidence needed, and in obtaining evidence pertinent to her claim under the VCAA. No useful purpose would be served in remanding this matter for yet more development. A remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit to the Veteran. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); & Quartuccio v. Principi, supra. Law and Analysis The Veteran seeks service connection for a low back disability that she contends was caused, or made worse, by her service-connected right knee and ankle disabilities. See VA Form 21-4138, received in May 2003. She presents evidence showing diagnoses of degenerative joint disease, degenerative disc disease, a mild broad base disc bulge at L4-5, as well as thoracolumbar spine strain. The Board notes that during the course of this appeal the claim for direct service connection for a back disability has also been denied. See Rating Decisions dated in August 2003, March 2004, and March 2006. While the Veteran has primarily limited her argument to principles of secondary service connection, the Board will analyze the back claim on both direct and secondary service connection bases. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). "To establish a right to compensation for a present disability, a Veteran must show: "(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"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). Service connection for certain specified chronic diseases, such as arthritis, may be established on a presumptive basis by showing that they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). (holding that the term "chronic disease in 38 C.F.R. § 3.309(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). A grant of service connection under 38 C.F.R. § 3.303(b) does not require proof of the nexus element; it is presumed. Id. Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). In order to establish service connection for a claimed secondary disorder, there must be medical evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). After considering all information and lay and medical evidence of record in a case 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 benefit of the doubt will be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The benefit of the doubt rule is inapplicable when the evidence preponderates against the claim. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Turning to the evidence in the current appeal, service treatment records show that, with the exception of complaints of back pain that appear to be associated with an ovarian cyst and/or pelvic inflammatory disease, the Veteran made no specific back complaints, and none are documented. In addition, there was no reference to a back disability at the time of her 1973 separation physical. Instead, a clinical evaluation of the spine was normal and the Veteran specifically denied a history of recurrent back pain. The post-service record is extensive, consisting of five volumes of evidence that includes VA outpatient treatment records, examination reports and medical opinions. These records cover a period from 1978 to 2012 and show the Veteran was involved in a motor vehicle accident in April 1978. However her injuries were confined to the right knee with no specific complaints or findings pertaining to the back. Rather the earliest medical evidence of any back problems is found in VA outpatient treatment records dated in 2002. See VA outpatient treatment record dated July 22, 2002. When examined by VA in July 2003, the Veteran complained of progressive difficulties involving the low back. Evaluation of the lumbar spine was negative for any evidence of paraspinal muscle spasm, but there was some decrease in range of motion. Radiographic findings of the lumbosacral spine were consistent with degenerative joint disease and degenerative disc disease. The clinical assessment was chronic lumbosacral strain. The examiner noted that the Veteran had undergone several right knee surgeries, including a patellectomy. There has been no history of current dislocation or subluxation, but the Veteran utilized a straight cane for ambulation and had bilateral knee braces. It was also noted that the Veteran had significant changes in her gait based on her right knee injury and that it was at least as likely as not that her current symptoms related to the other joints are related to her service-connected right knee injury. However, there was no specific opinion regarding etiology of the lumbar joint disease/disc disease offered. VA outpatient treatment records dated in September 2003 show the Veteran was evaluated for hip and back injuries after she fell when her right knee gave out. Although X-rays of the lumbar spine were negative, a computer tomography (CT) scan showed a mild broad base disc bulge at L4-5. The Veteran underwent additional VA examination in January 2004. At that time the VA examiner reviewed the claims file, including service treatment records and post-service VA outpatient treatment reports and summarized the history and findings reflected by these records. The Veteran's history of post-service injury as a result of falling after her service-connected right knee gave way and current medical problems were also noted. On examination there was no pain to palpation along the spinous column and no spasms, but there was mild tenderness in the left ileal lumbar joint and she had decreased lumbar spine motion. The Veteran's stance and ambulation were both normal. The examiner referred to the previous CT scan showing minor disc bulge at L4-5, but then noted that magnetic resonance imaging (MRI) of the lumbar spine taken the day prior was normal with no bulged or herniated discs and no evidence of spinal stenosis. The examiner concluded that the Veteran's disc bulge "had been relieved or reduced by phy[sical] therapy and the rest [that] she . . . [has] been . . . receiving." Still, the January 2004 examiner diagnosed the Veteran with mild degenerative joint disease of the lumbar spine, but did not provide an opinion addressing its etiology or likely time of onset. In a March 2004 written statement, the Veteran reported that she had spoken with a registered nurse and was told that "the MRI does not always show what a CT does because the MRI is positional." The Veteran then noted that she had been lying flat when the CT was performed, but had pillows under her head and knees when the MRI was taken. Subsequent VA medical records include an April 2004 discharge summary that shows the Veteran was admitted for rehabilitation due to mobility impairment following a right total knee replacement. At that time X-rays of the thoracic spine showed mild lower thoracic levoscoliosis. Subsequently dated records show the Veteran underwent surgery for a perineal tendon lengthening on the right side to improve her gait biomechanics. See VA orthopedic consultation note dated August 1, 2006. In March 2009, the Board remanded the Veteran's claim for service connection for a back disability to afford the agency of original jurisdiction an opportunity to obtain a medical opinion with respect to etiology, in part due to the fact that the medical records were positive for chronic low back pain. Specifically, the report of the examination was to include a notation from the examiner that he/she had reviewed the claims file in conjunction with the evaluation as well as provide an opinion as to the etiology of any diagnosed back disability. Following an April 2009 VA examination, the examiner diagnosed thoracolumbar spine strain and opined that it was "at least as likely as not that the patient's chronic back disability [wa]s aggravated by a service-connected right ankle tendinitis [sic] and right ankle and knee replacement." The examiner explained that, "during these times when she went through right ankle surgeries and right knee surgeries her back pain became exaccerbated [sic]." Unfortunately, the physician did not indicate, as required by the Board's March 2009 Remand, that she had reviewed the claims folder. In fact, the examiner noted that the Veteran was "a poor historian . . . [who gave] some conflicting information . . . [and who was, thus,] difficult to follow at times." Significantly, the April 2009 VA examiner did not address the 1978 post-service injury to the Veteran's back. That following month the RO received a medical opinion from a VA physician who reported treating the Veteran for her knee and ankle problems, and who performed recent surgery on her knee. He admitted that he does not render medical care to the Veteran for her back symptoms, but then went on to opine that "it has been . . . [his] experience that injuries and diseases of the knee and ankle frequently result in gait abnormalities that result in consequential back disability . . . [and that the Veteran] has had sufficient gait abnormalities to result in some measure of back disability." See VA Progress Note dated May 19, 2009. While acknowledging that the record contains evidence of the Veteran's gait abnormalities resulting from her service-connected right ankle and right knee disabilities, the Board found that the May 2009 VA doctor's opinion was too speculative to be probative for several reasons. First, the physician did not specify the nature and extent of the Veteran's current back disability. [Indeed, as noted herein, the doctor admitted that he does not treat the Veteran for her back symptoms.] Second, the physician simply concluded that the Veteran's gait abnormalities have resulted in "some measure of back disability." Third, the examiner did not address the effect, if any, of the 1978 post-service motor vehicle accident on the Veteran's current back condition. Clarification of the effect of the Veteran's service-connected right ankle and right knee disabilities, on her back condition, was, therefore, necessary. See Board Remand dated in March 2010. Pursuant to the Board's March 2010 Remand, the Veteran underwent VA examination in January 2012. The examiner interviewed the Veteran and reviewed the claims file in its entirety, including the previous 2009 VA examination report, test results, and clinical reports from treating physicians, as well as review the Veteran's history of low back injury sustained in the slip and fall accident. The examiner noted the Veteran currently had no disc issues, but instead just bilateral lower back pain primarily in both hip regions. Referring to the April 2009 radiological findings, the examiner noted the lumbar spine was essentially normal with vertebral bodies were of normal height, normal alignment, and no significant arthritic changes. There was no evidence of spondylolysis or spondylolisthesis. The VA examiner ultimately concluded that there was no objective evidence of a chronic lower back condition and as such did not provide a medical opinion. The Board noted, however, that the Court has held that to be present as a current disability, there must be evidence of the condition at some time during the claim period. Gilpin v. West, 155 F. 3d 1353, 1356 (Fed. Cir. 1998); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the Gilpin requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves). As the Veteran submitted her back claim in May 2003 when diagnosed with degenerative joint disease, degenerative disc disease, and lumbar strain, a medical opinion was considered necessary to determine the etiology of those findings, to include whether they were due to service or were secondary to the service-connected right knee and ankle disabilities. See Board Remand dated in April 2013. The Veteran was scheduled for additional VA examination in May 2013, but did not report for the examination and has not offered any explanation for her absence or requested to reschedule. Unfortunately, her failure to cooperate with the requested VA examination served to deprive the Board of critical, clarifying medical evidence which might have helped support her claim. So, as it stands, the record does not contain a competent medical opinion as to whether the Veteran's back disorder is related to any service-connected disability. As a result, the Board is unable to attribute any post-service back problems, including chronic lumbar strain, degenerative joint disease, and degenerative disc disease to her service-connected right knee and right ankle disabilities. There is no probative and competent medical evidence of record to indicate that a service-connected disability plays any role in the development or worsening of her claimed back disability. The weight of the competent and/or credible lay or medical evidence - for the reasons discussed above and as will be elaborated on in the conclusion section below - is against the Veteran's claim that her current back problems are related to any service connected disability. Absent evidence of a nexus between the claimed condition and the service-connected disability, service connection cannot be granted on a secondary basis. 38 C.F.R. § 3.310; Allen, supra. The Board is also unable to attribute the post-service development of any back disorder to the Veteran's military service. The service treatment records, as a whole, provide negative evidence against this claim. They show neither complaints nor evidence of a chronic back disorder in service and there is no evidence that degenerative joint disease (arthritis) was manifested in the first post-service year. Moreover post-service treatment records do not show that the disc/joint disease first documented in 2003, 30 years post service, was manifested prior to that date. Also, during those intervening years the Veteran did not complain of or receive treatment for any pertinent back symptoms consistent with 38 C.F.R. § 3.303(b). Although not a dispositive factor, the significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000). What remains for consideration is whether or not in the absence of a diagnosis in service and/or continuity of symptoms the Veteran's diagnosed degenerative joint disease/disc disease may nonetheless somehow otherwise be related to his service. However, there is no medical evidence linking the Veteran's diagnosed back disorder to her military service years earlier, and she has not submitted any medical opinion that relates them to her service/events therein. See Hickson v. West, 12 Vet. App. 247. In reaching these conclusions, the Board notes that despite the lack of definitive medical nexus opinion in this case, medical evidence is not always or categorically required in every instance to establish the required nexus or linkage between the claimed disability and the Veteran's military service or service connected disability. Here, as already alluded to, the claim is primarily predicated on the notion that the Veteran's back problems are related to her service-connected right knee and/or ankle disabilities. The Board is keenly aware that lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994) Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The United States Court of Appeals for the Federal Circuit (Federal Circuit Court) also held in Buchanan (and Davidson and Jandreau), however, that the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. So to ultimately have probative value, the Veteran's assertions also have to be credible and judged in relation to the other evidence in the file - including any medical evidence addressing the determinative issue of causation. See Rucker v. Brown, 10 Vet. App. 67 (1997) and Layno, 6 Vet. App. at 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). Throughout the claim process, the Veteran has been very consistent in her description of her back injury. Moreover, her account of that injury is corroborated by post-service treatment records referencing the gait abnormalities resulting from her service-connected right ankle and right knee disabilities and the slip and fall accident in 2003. Thus, based on the evidence submitted in support of her claim, the Board finds the Veteran to be credible with respect to her assertions. However, the Board finds the Veteran's contentions as to the etiology of her claimed back disability are of limited probative value under the circumstances. The medical issues in this case are fairly complex because they deal with degenerative disc disease and degenerative joint disease, disorders that require specialized training and equipment for a determination as to diagnosis and causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating and determining causal connections for orthopedic disorders, disc disease or joint disease. King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. Although the Board recognizes the sincerity of the arguments advanced by the Veteran in this case, her contentions regarding the etiology of her claimed back disability are not statements merely about symptomatology, an observable medical condition, or a contemporaneous medical diagnosis, but rather clearly fall within the realm of requiring medical expertise, which she simply does not have. That is to say, joint disease/disc disease are not the types of conditions that are readily amenable to mere lay diagnosis or probative comment on their etiology. The Board acknowledges the Veteran's competency as to the symptoms experienced and their possible etiological relationship to an injury and/or problems with an altered gait. However, whether there is actually any cause and effect relationship, and by this the Board means either that the right knee/ankle caused or aggravated her back problems, is not answered by her report of symptoms. Despite symptoms that often may be associated with an eventual diagnosis of join and/or disc disease, the Veteran is not in turn competent to ascribe these symptoms to a disorder related to a service-connected disability or military service. As was noted in the discussion throughout the decision, VA attempted to get a more complete and authoritative medical opinion, but the Veteran did not appear for the scheduled examination. Accordingly, the preponderance of the evidence is against the claim and there is no reasonable doubt to be resolved. 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for a back disability, on a direct basis and as secondary to a service-connected disability, is denied. ____________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs