Citation Nr: 1334437 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 06-13 356 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for a low back disorder, to include as secondary to service-connected meniscus tear of the left knee and/or service-connected status post fracture of the right distal fibula with a fracture of the lateral malleolus of the right ankle. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The Veteran had active military service in the United States Navy from July 1975 to July 1981 with additional service in the United States Air Force Reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Board notes that the issues of entitlement to an initial rating in excess of 10 percent for status post fracture of the right distal fibula with a fracture of the lateral malleolus of the right ankle, and entitlement to service connection for bilateral hearing loss, tinnitus, cellulitis of both feet, and a left shoulder disorder were previously before the Board in November 2012. At such time, the Board dismissed the issue of entitlement to a higher initial rating for the Veteran's right ankle disability as he had withdrawn such issue. Additionally, the Board also remanded the issues of entitlement to service connection for low back disorder, bilateral hearing loss, tinnitus, cellulitis of both feet, and a left shoulder disorder for additional development. While on remand, a February 2013 rating action granted service connection for hearing loss and tinnitus, and assigned initial disability ratings and effective dates of award. As such awards of service connection were a full grant of the benefits sought on appeal, such issues are no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). In a May 2013 decision, the Board denied service connection for cellulitis of both feet and remanded the claims for service connection for a left shoulder disorder and a low back disorder. Thereafter, a July 2013 rating decision granted service connection for left shoulder bursitis with anterior rotator cuff tear and assigned an initial 10 percent rating, effective January 14, 2005. As such award of service connection was a full grant of the benefit sought on appeal, such issue is no longer before the Board. Id. The issue of entitlement to service connection for a low back disorder now returns for further appellate review. The Veteran testified at a hearing before a Decision Review Officer (DRO) at the RO in November 2008. He also testified before the undersigned Veterans Law Judge (VLJ) sitting at the RO in August 2012. Transcripts of both hearings are contained in the claims file. In addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's appeal. A review of the Virtual VA paperless claims processing system reveals additional VA treatment records that have been considered by the AOJ in various supplemental statements of the case, and the Veteran's representative's August 2013 Appellant's Brief. In the May 2013 decision, the Board noted that, in a statement received in March 2013, the Veteran raised the issue of entitlement to service connection for an acquired psychiatric disorder, claimed as secondary to his service-connected disabilities. As yet, that claim has still not been adjudicated and, so, it is again referred to the AOJ for appropriate action. FINDINGS OF FACT A low back disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service; arthritis did not manifest within one year of the Veteran's discharge from active duty; and is not caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for a low back disorder are not met. 38 U.S.C.A. §§ 101, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice, as required by 38 U.S.C.A. § 5103(a), was intended to be provided to a claimant before the initial unfavorable AOJ decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, an April 2009 letter, sent prior to the initial unfavorable decision issued in June 2009, and an August 2010 letter advised the Veteran of the evidence and information necessary to substantiate his service connection claim on a direct and secondary basis as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letters advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. While the August 2010 letter was issued after the initial June 2009 rating decision, the United States Court of Appeals for the Federal Circuit has held that VA could cure such a timing problem by readjudicating the Veteran's claim following a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006). The Court clarified that the issuance of a statement of the case could constitute a readjudication of the Veteran's claim. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after the August 2010 letter was issued, the Veteran's claim was readjudicated in the August 2011 rating decision, January 2012 statement of the case, and May 2012, March 2013, and August 2013 supplemental statements of the case. Therefore, any defect with respect to the timing of the VCAA notice has been cured. Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The AOJ has obtained the Veteran's service treatment records (STRs) for his period of active duty from July 1975 to July 1981. The AOJ was unable to obtain complete records from the Veteran's service in the Army National Guard. In August 2009, the AOJ made a formal finding of unavailability of these STRs, and notified the Veteran of those unavailable records in August 2009. Notably, the February 2005 VCAA letter contained notice of the alternative types of records which could help supplement missing STRs. Additionally, the Veteran has not claimed treatment for cellulitis during his Army National Guard service. He also denies being provided a separation examination as this was a period of active duty for training (ACDUTRA). The AOJ has also obtained all VA clinic records identified by the Veteran, and all relevant private medical records for which the Veteran has identified and authorized VA to obtain on his behalf. The Board is unaware of any relevant records in the possession of the Social Security Administration, and the Veteran has not identified any other pertinent records for the AOJ to obtain on his behalf. Moreover, as recently a September 2013 the Veteran reported, in writing, that he had no further information or evidence to submit. The Veteran was also afforded VA examinations in January 2011 and December 2012 with addendum opinions obtained in June 2013 and August 2013 with respect to the issue decided herein. The Board finds that such VA examinations and opinions are adequate to decide the issue as they are predicated on an interview with the Veteran; a review of the record, to include his service treatment records; and a physical examination with diagnostic testing. The opinions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. The Board notes that the January 2011 VA examiner determined that the Veteran's current low back disorder is not caused by or a result of his service-connected disabilities, but failed to address whether such is directly related to his active military service, to include his October 1990 in-service fall or aggravated by his service-connected disabilities. Therefore, the Board remanded the case in November 2012 so as to afford the Veteran another VA examination with an adequate opinion. Thereafter, in December 2012, an opinion regarding whether the Veteran's back disorder is related to his October 1990 in-service fall was obtained; however, no opinion regarding whether his service-connected disabilities aggravated his back disorder. Therefore, the Board again remanded the case in May 2013 so as to obtain the proper opinions. Thereafter, opinions were obtained in June 2013 and August 2013 that full address direct and secondary service connection. Furthermore, the Board finds that the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet.App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In the Veteran's representative's August 2013 Appellant's Brief, it was alleged that the August 2013 opinion is inadequate. In this regard, the Veteran's representative claimed that, while the examiner noted the Veteran's 1990 fall, but reverted back to the 1981 separation examination and noted that such was negative for a back condition. While the August 2013 VA examiner did note that the 1981 separation examination was negative, such a finding is relevant to whether the Veteran manifested arthritis as a chronic disease within one year of his discharge from active duty. Moreover, as observed by the Veteran's representative, the VA examiner specifically considered the 1990 injury in rendering his opinion regarding whether the Veteran's back disability is related to such injury. The Veteran's representative further alleges that the August 2013 opinion is inadequate as the examiner noted that the Veteran first complained of a back condition in 2009 when, in fact, he complained of low back pain in December 1992. The Board finds that the Veteran's representative has mischaracterized the examiner's statement in that, the August 2013 opinion stated that the Veteran's "first complaint of lower back pain was filed in 2009." Taken in context, the examiner meant that the Veteran's first "claim" for low back disability was filed in 2009, as in fact it was. Therefore, the Board accords no weight to the Veteran's representative's allegations regarding the adequacy of the August 2013 VA opinion. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the issue decided herein has been met. The Board further finds that the AOJ has complied with the Board's remand directives. In this respect, the AOJ obtained updated VA treatment records and sent the Veteran a letter in November 2012 asking him to identify any additional relevant records. In response, he indicated that all his treatment was through VA. Additionally, the AOJ obtained an adequate VA medical opinions in December 2012, June 2013, and August 2013 and readjudicated the claim in the March 2013 and August 2013 supplemental statements of the case, as directed in the November 2012 and May 2013 remand orders. As such, the Board finds that the AOJ has substantially complied with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). The Veteran testified at a November 2008 RO hearing before a DRO and at an August 2012 Board hearing before the undersigned VLJ. Bryant v. Shinseki, 23 Vet. App. 488 (2010) held that 38 C.F.R. § 3.103(c)(2) requires that the RO DRO and/or Board VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the November 2008 and August 2012 hearings, the Veteran was assisted by accredited representatives, and such representatives and the DRO and undersigned VLJ asked questions to ascertain the extent of any in-service event or injury, the type of symptomatology experienced by the Veteran, his treatment history, and the availability of any pertinent records. Moreover, the Board remanded the case in November 2012 in order to obtain any outstanding records and in November 2012 and May 2013 to obtain an addendum opinion regarding the etiology of the Veteran's low back disorder. Thus, no pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or his representative that was not obtained while the appeal was in remand status or is not available. Moreover, the hearing focused on the elements necessary to substantiate the claim. Therefore, the Board finds that, consistent with Bryant, the DRO and undersigned VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). To the extent that there were any deficiencies, they were cured with the Board's November 2012 and May 2013 remands for outstanding records and addendum opinions. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). Background The STRs of the Veteran's service from 1975 to 1981 show that he fractured his right ankle in an August 1977 injury. Extensive records of treatment and evaluation for that injury, as well as all of the STRs during that period of service, are negative as to his low back. Likewise, his May 1981 separation examination was negative as to his low back. STRs show that in October 1990 the Veteran fell from a telephone pole and injured his left knee. There was no mention, complaints, treatment or evaluation of low back disability. Records of the Ochsner Clinic from 1992 to 2005 show that, in December 1992, the Veteran complained of back pain, but had no previous back problems. Lumbar X-rays were normal and his disc spaces were normal. In January 1993, he had sciatica affecting his left leg. In the Veteran's original claim for VA compensation benefits, received in January 2005, he made no mention of any back injury or back disability. On VA examination in June 2005 the Veteran's gait was normal. He was 72 inches in height and weighed 225 lbs. In a June 2007 statement Dr. R. T. of the Ochsner Clinic addressed the etiology of the Veteran's disabilities of the right leg and ankle, left shoulder, hearing loss, and left knee, but not any disability of the low back. A VA clinical record dated in September 2008 reflects that the Veteran had a six-month history of low back pain with radiation of pain down the left leg. A June 2009 VA outpatient treatment record shows that the Veteran had a waddling type gait, mildly so, with right foot eversion. In July 2010 Dr. R. T. reported that the Veteran's chronic back pain and left sciatica appeared more likely than not to be related to two service-related injuries, regarding a right ankle fracture in 1977 and the left knee in 1990. In addition to the immediate damage, the altered gait produced by these injuries had stressed his low back, producing the late sequelae. On VA spine examination in January 2011, the Veteran's claim file was reviewed. The Veteran reported the onset of low back and left knee pain in about 1995, about 6 months after he fell from a telephone pole. He had fractured his right ankle in 1979 in the Navy. On examination, there was no evidence of leg shortening and no evidence in the feet of abnormal weight-bearing. Lumbar X-rays revealed mild degenerative changes. The diagnoses were an old right ankle fracture, a torn left knee medial meniscus with degenerative joint disease (DJD), and lumbar spine DJD and degenerative disc disease (DDD). The VA examiner determined that the Veteran's current low back disorder is not caused by or a result of his service-connected disabilities. In this regard, he noted that the Veteran had not sought treatment for his low back until 1997, having had the gradual onset of low back pain associated with a new right ankle twisting injury in 1997 or 1998, and a twisting injury of the left knee. He was 71 inches in height and weighed 240 lbs. The examiner stated that the changes in the Veteran's lumbar spine were compatible with a chronic condition. His left knee and right ankle disabilities had caused minimal, if any, abnormalities of gait/posture based on his having a normal gait and normal range of motion of the ankle on examination in 2006. Even accepting an occasional giving way of his ankle to cause a lurch, they had not contributed to significant stressful mechanics of the low back. But, the Veteran's chronic every day, all day significant obesity had contributed to stressful mechanics of the low back due to the chronic lumbar lordosis, which had been present since at least 2006 according to weight records, and [the obesity] was the likely cause of accelerated aging of the lumbar spine. On VA examination in December 2012, it was reported that the Veteran had lumbar DJD with radiculopathy. He claimed that he had fallen from a telephone pole in 1990 and developed low back pain secondary to altered gait from the telephone pole injury in 1992. On examination, he had guarding or muscle spasm of the thoracolumbar spine but not the resulting in abnormal gait or spinal contour. He had pain, paresthesia or dysesthesias (or both), and numbness of the left lower extremity, in the sciatic nerve distribution. However, it was reported that he did not have intervertebral disc syndrome (IVDS). It was commented that arthritis was documented. The examiner opined that the Veteran's claimed low back condition was not the result of a fall down a telephone pole. He had a May 1981 separation examination that was normal without a back condition, and there were no records of a follow-up for his back after discharge and no claim was filed until 2009. The Veteran's claim files were reviewed in June 2013 by a VA physician. The physician checked a box in the Disability Benefits Questionnaire (DBQ) which indicated that: The claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The VA physician then stated that that the Veteran's low back disorder had not been increased in severity beyond the natural progression by his service-connected meniscus tear of the left knee and/or his service-connected status post fracture of the right distal fibular with fracture of the lateral malleolus of the right ankle as the Veteran would have to have a significant leg length discrepancy causing a significant 'limp' to produce an increased pain in his back. In light of the June 2013 VA examiner's opinion, it appears that he checked the incorrect box regarding the existence of a back disorder prior to the Veteran's service. Moreover, there is no allegation of an injury to the back until 1990 and no evidence of back complaints until 1992. Therefore, despite the fact that the examiner checked the wrong box, there is no evidence that a back disorder pre-existed the Veteran's entrance to military service in 1975 or his entrance onto ACDUTRA in 1990. In June 2013, Dr. R. T. stated that, more likely than not, the Veteran's back disability "was at least contributed to" by the October 1990 fall of 30 feet from a telephone. He further stated that, "while obesity is also a contributing factor his limited exercise tolerance due to his [service-connected] knee, ankle, and shoulder injuries as well as ongoing back problems is likewise a contributing factor to his obesity." Another VA medical opinion was obtained in August 2013. The claim files were reviewed. It was concluded that it was less likely than not that the Veteran's back condition was aggravated beyond its natural and normal progress by his service-connected left knee condition and/or status post fracture of the right distal malleolus (lateral aspect of ankle). The opinion was based on a comprehensive review of the clinical files, the private records, radiographs, and current medical literature. The physician reported the salient facts that he relied upon, to include a negative separation examination in 1981, a July 2009 MRI, and the August 2009 X-rays which found only mild degenerative lumbar change and very mild L4-5 disc space narrowing, suggesting only mild lumbar degenerative disc disease. X-rays in August 2010 were consistent with this, noting only very mild narrowing at L4-5 and L5-S1. The physician in August 2013 concluded that it was at least as likely as not that the Veteran's low back pain was consistent with the normal and natural aging process due to the mild degenerative changes consistent with age. Conversely, it less likely than not had a nexus to his injury in 1990, or a nexus to his left knee condition or aggravated beyond its natural and normal aging process. In support of this that physician noted that the Veteran was obese. The August 2013 VA physician stated that her opinion was consistent with the December 2012 examination and the June 2013 opinion. Law and Regulations A Veteran is a person who served in the active military, naval, or air service and who was discharged or released under conditions other "than dishonorable." 38 C.F.R. § 3.1(d). The term "active military, naval, or air service" includes: (1) active duty; (2) any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of inactive duty for training during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty. 38 U.S.C.A. § 101(24) ; 38 C.F.R. § 3.6(a). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, to include arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Board must weigh any competent lay evidence and to make a credibility determination as to whether it supports a finding of service incurrence; or, if applicable, continuity of symptomatology; or both, sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Layno v. Brown, 6 Vet. App. 465 (1994). The credibility of lay evidence may not be refuted solely by the absence of corroborating contemporaneous medical evidence, but it is a factor. Davidson, 581 F.3d at 1316 (Fed.Cir. 2009). Other credibility factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). 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 Veteran. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Analysis At his DRO and Board hearings, as well as in documents of record, the Veteran contends that he has a low back disability due an injury in October 1990 or due to the combined affect of his service-connected disabilities of the lower extremities. He alleges that these disabilities caused impaired gait and led him to be inactive to such a degree that he became overweight. Thus, it was not being overweight which led to his abnormality gait. Rather, his abnormal gait has caused the low back disability for which he seeks service connection. The STRs of the Veteran's service from 1975 to 1981 are completely negative for low back disability, despite his having undergone extensive treatment and evaluation for his now service-connected residuals of an injury of the right lower leg. Nor is there evidence of any lumbar arthritis within one year of his May 1981 separation. Moreover, the Veteran has not alleged a continuity of back symptomatology since his May 1981 discharge from active duty. Rather, he contends that his initial injury to the back was 1990. Therefore, the Board finds that presumptive service connection for arthritis of the spine, to include on the basis of continuity of symptomatology, is not warranted. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. The STRs show that, during a period of duty in the Air Force Reserves, apparently ACDUTA, in October 1990, the Veteran fell from a pole and injured his left knee. As noted, he is now service-connected for a menisceal tear of the left knee from this injury. The Veteran now contends that he also injured his low back due to this same event. The STRs of the Veteran's service in 1990 reflect numerous complaints, treatment, and evaluation for the left knee injury he sustained in October 1990. However, none of the records make any reference to a low back injury, much less any complaints, treatment, and/or evaluation for a low back disability. In fact, when the Veteran had an opportunity to claim service connection for low back disability in 2005, no mention was made of a low back disability. Similarly, the earliest evidence pertaining to his low back is dated in December 1992, when it was specifically noted that he had low back pain, but no prior back problems. Significantly, lumbar X-rays at that time were normal. Consistent with this is the September 2008 VA record that reflects that the Veteran had only a six-month history of low back pain. As the Veteran's statements that he has continuously had low back pain since his October 1990 fall from a telephone pole are not supported by the contemporaneous records and, in fact, are directly contradicted by such evidence, the Board finds the Veteran's statements to be not credible. Specifically, as the Veteran's treatment records were generated with a view towards ascertaining his then-state of physical fitness, they are akin to statements of diagnosis and treatment and are of increased probative value. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that, although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). Moreover, despite alleging a back injury as well as a left knee injury at the time of the 1990 fall, the Veteran only claimed service connection for his left knee injury in his original application for benefits in January 2005. Therefore, his allegation that he has experienced back problems since the 1990 injury is directly contradicted by his January 2005 claim for VA benefits. Therefore, the Board finds that the Veteran's statements regarding continuity of back symptomatology since the time of his October 1990 fall from a telephone pole to be not credible and they are afforded no probative weight. The Board further finds that the weight of the probative evidence is against his claim that his back disorder is directly related to his October 1990 fall from a telephone pole while serving on ACDUTRA. In this regard, the August 2013 VA examiner determined that the Veteran's back disorder was not related to such a fall, but more likely related to the normal and natural aging process. The Board accords great probative weight to the August 2013 VA examiner's opinion as he took into account the Veteran's reported history, the medical records, and physical findings, to specifically include X-ray results. Moreover, his opinion is consistent with the evidence of record in which the Veteran's STR's from his 1990 injury are negative for complaints, treatment, or diagnoses referable to his back; the Veteran's first complaint of back pain was in 1992, at which time he indicated that he had no previous back problems; his failure to file a claim for service connection for a back disorder at the time he filed his initial claim for benefits in January 2005; and his September 2008 reported that he had a six-month history of back pain. Therefore, the Board places great probative weight on the August 2013 VA examiner's opinion. See Nieves-Rodriguez, supra; Stefl, supra. In contrast, Dr. R.T. opinion in June 2013 that it was more likely than not that the Veterans' back disability "was at least contributed to" by the October 1990 fall, he offered no rationale for such opinion and cited no supporting evidence. As such opinion fails to provide supporting data as well as reasoned medical explanations connecting the two, the Board accords it no probative weight. Id. Therefore, the Board finds that the probative weight is against the Veteran's claim that his back disorder is directly related to his 1990 injury. The Board further finds that secondary service connection for the Veteran's back disorder is not warranted. In this regard, the January 2011 VA examiner determined that the Veteran's current low back disorder is not caused by or a result of his service-connected disabilities. The examiner stated that the changes in the Veteran's lumbar spine were compatible with a chronic condition. His left knee and right ankle disabilities had caused minimal, if any, abnormalities of gait/posture based on his having a normal gait and normal range of motion of the ankle on examination in 2006. Even accepting an occasional giving way of his ankle to cause a lurch, they had not contributed to significant stressful mechanics of the low back. But, the Veteran's chronic every day, all day significant obesity had contributed to stressful mechanics of the low back due to the chronic lumbar lordosis, which had been present since at least 2006 according to weight records, and [the obesity] was the likely cause of accelerated aging of the lumbar spine. Likewise, the June 2013 and August 2013 VA examiners opined that the Veteran's low back disorder had not been increased in severity beyond the natural progression by his service-connected meniscus tear of the left knee and/or his service-connected status post fracture of the right distal fibular with fracture of the lateral malleolus of the right ankle as the Veteran would have to have a significant leg length discrepancy causing a significant 'limp' to produce an increased pain in his back. Rather, the August 2013 VA examiner determined that it was more likely than not that in August 2013 concluded that it was at least as likely as not that the Veteran's low back pain was consistent with the normal and natural aging process due to the mild degenerative changes consistent with age. As the VA examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two, the Board accords great probative weight to their opinions. See Nieves-Rodriguez , supra; Stefl, supra. In contrast, while Dr. R. T. stated in 2010 that the Veteran's current low back disability appears to be more likely related to two injuries, i.e., the right ankle during the first period of service, and the left knee in 1990, as the altered gait produced by such injuries had stressed the Veteran's low back, he offered no rationale for that opinion. Id. Additionally, Dr. R. T. has indicated in the 2010 statement, and again in an 2013 statement, that the Veteran's service-connected lower extremity disabilities caused an altered gait resulting in low back disability or at least were contributing factors in his becoming obese (and by inference obesity contributing to the development of low back disability). However, the Board finds that the evidence of an altered gait is not persuasive. While a 2009 VA treatment record indicates the Veteran had a waddling gait, no abnormality of his gait was reported on VA spinal examinations in 2011 and 2012 and, if such an abnormality existed, it is expected that it would have been recorded at those times. Moreover, the June 2013 VA physician concluded that for there to be a significant limp, there would have to also be a significant leg length discrepancy. Here, the evidence does not show that there is any significant leg length discrepancy. Therefore, the Board accords no probative weight to Dr. R.T.'s opinions. The Board also finds the inference that the service-connected lower extremity disabilities led to such a sedentary life as to cause obesity which, in turn, caused or contributed to the current low back disability is simply too tenuous and is not otherwise supported by the evidence of record. Specifically, the probative evidence of record reflects that the Veteran's back disorder was consistent with the normal and natural aging process. Again the Board finds that the most persuasive opinions are those expressed by two VA physicians in June 2013 and August 2013. Each physician reviewed the claims files and, as noted by the August 2013 VA physician, the opinions are consistent with each other. The August 2013 VA physician found, in essence, that the Veteran's current low back disability was not related to any inservice injury in 1990 or to the service-connected lower extremity disabilities, but was most consistent with the normal aging process. And consistent with this is the fact that the earliest radiologically documented abnormalities of the Veteran's lumbar spine do not pre-date 2009, at time almost two decades after his service in 1990. In reaching such conclusions, the Board has considered the Veteran's lay statements that his back disorder is the result of his 1990 injury or, in the alternative, caused or aggravated by his service-connected left knee and right ankle disabilities. However, as a lay person, he is not competent to offer such a complex medical opinion. In this regard, he is competent to describe an in-service injury, such as a fall, as well as his current back pain; however, as the cause of such a disability involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, he is not competent to render such a complex medical opinion. In this regard, diagnosing a back disorder and determining the etiology of such involves examination and specialized testing, as well as knowledge of the result of trauma to the spine and the impact, if any, of disabilities of the lower extremities on the spine. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board finds that service connection for a low back disorder is not warranted. 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 of entitlement to service connection for a low back disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for a low back disorder is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs