Citation Nr: 1334447 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 07-23 614 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to service connection for a chronic low back disability claimed as degenerative disc disease (DDD) and degenerative joint disease (DJD) of the lumbar spine. 2. Entitlement to service connection for a right wrist disorder, to include carpal tunnel syndrome (CTS) and DJD of the right wrist. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The Veteran served on honorable active duty from June 1973 to June 1975 in the United States Army, and then from August 1975 to August 1977 in the United States Navy, and then from January 1979 to January 1983 in the United States Coast Guard. These matters come to the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines, which determined that new and material evidence had been submitted with respect to the Veteran's previously denied claims for service connection for DDD and DJD of the lumbar spine and CTS of the right wrist, reopened the claims for a de novo review, and then denied the claims on the merits. During the course of the appeal, the Veteran appeared before a Decision Review Officer (DRO) and submitted oral testimony in support of his claim at a February 2007 hearing. The Veteran also appeared before the undersigned and submitted oral testimony in support of his claim at an October 2008 Board videoconference hearing. The Board observes that the transcripts of both hearings have been obtained and associated with the Veteran's claims file. In a December 2008 decision, the Board affirmed the RO's finding of new and material evidence and remanded the claims so that the Veteran's Social Security Administration (SSA) records could be obtained for inclusion in the evidence. Following this evidentiary development, the denials of service connection for DDD and DJD of the lumbar spine and CTS of the right wrist were confirmed in an August 2009 supplemental statement of the case (SSOC). In July 2011, the Board remanded these matters for additional evidentiary development. Denials of service connection for DDD and DJD of the lumbar spine and CTS of the right wrist were confirmed in an October 2011 SSOC. The appeal was thereafter returned to the Board and the Veteran now continues his appeal. In addition, during the pendency of this appeal, the Court addressed the scope of a claim in regard to a claimed disability in Clemons v. Shinseki, 23 Vet. App. 1 (2009). In Clemons the Court held that, in determining the scope of a claim, the Board must consider the Veteran's description of the claim; symptoms described; and the information submitted or developed in support of the claim. Id. at 5. In light of the Court's decision in Clemons and the varying diagnoses of right wrist CTS and DJD, the Board has recharacterized the issue on appeal as stated on the title page. This will provide the most favorable review of the Veteran's claim in keeping with the Court's holding in Clemons. The record before the Board consists of the Veteran's paper claims file and an electronic file known as Virtual VA. FINDINGS OF FACT 1. Although the Veteran reported subjective complaints of low back pain after documented in-service motor vehicle accident and fall injuries, the current, chronic low back disability, claimed as DDD and DJD of the lumbar spine, was not directly related to any event, injury, or disease in service, was not the result of aggravation of pre-existing congenital lumbar anomalies by service, and arthritis was not manifest to any degree within one year after discharge from service. 2. Although the Veteran reported subjective complaints of right wrist pain and was treated for right wrist strain on an isolated instance in service, the current right wrist disorder did not have its onset during active service, was not the result of an event, injury, or disease incurred in active service, and arthritis was not manifest to any degree within one year after discharge from service. CONCLUSIONS OF LAW 1. A chronic low back disability was not incurred in or aggravated by active military service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 1111, 1131, 1153, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306, 3.307, 3.309 (2013). 2. A right wrist disorder was not incurred in active service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist With respect to the Veteran's service connection claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. The RO's July 2004, September 2005, and July 2008 letters provided before and after the initial adjudication of the service connection claims on appeal in April 2006, advised the Veteran of the foregoing elements of the notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). These letters also provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Accordingly, with these letters, the RO effectively satisfied the remaining notice requirements with respect to the issues on appeal. After the notice letters were provided to the Veteran, the claim was readjudicated in an October 2011 SSOC. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (finding that VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's available service treatment records, records from the Social Security Administration (SSA), and post-service private and VA treatment records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran was also provided with VA medical opinions in conjunction with the claims on appeal in May 2007 and August 2011 to determine the nature and etiology of his claimed low back and right wrist disorders. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159; see McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). The Board has found the August 2011 VA medical opinion was adequate, as it was based upon a complete review of the evidence of record, consideration of conflicting medical evidence, and earlier clinical examination findings of the Veteran. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Finally, the Veteran's claims were previously before the Board in December 2008 and July 2011 and remanded for additional evidentiary development, to include obtaining outstanding SSA records and VA medical opinions. The Board finds that there has been substantial compliance with the December 2008 and July 2011 remand orders. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection for certain disabilities, including arthritis, may be granted on a presumptive basis if manifested to a compensable degree within one year after separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.307, 3.309 (2013). In addition, service connection on the basis of continuity of symptomatology can only be established for the chronic diseases as specified at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clearcut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2013). Service connection may also be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d) (2013). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, 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. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Every person employed in the active military, naval, or air service shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111, 1137 (West 2002 & Supp. 2013); 38 C.F.R. § 3.304(b) (2013). Prior provisions of 38 C.F.R. § 3.304(b) only required a finding that clear and unmistakable evidence showed that a injury or disease existed prior to service in order to rebut the presumption of soundness. However, the provisions of 38 C.F.R. § 3.304(b) were invalidated as being inconsistent with 38 U.S.C.A. § 1111. See generally Cotant v. Principi, 17 Vet. App. 116 (2003); Jordan v. Principi, 17 Vet. App. 261 (2003); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); VAOPGCPREC 3-2003 (July 16, 2003). In July 2003, VA's General Counsel issued a precedent opinion holding that to rebut the presumption of soundness in 38 U.S.C.A. § 1111, VA must show, by clear and unmistakable evidence, that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. Id. Pursuant to these developments, it is now clear that in order to rebut the presumption of soundness at service entry, there must be clear and unmistakable evidence showing that the disorder preexisted service and there must be clear and unmistakable evidence that the disorder was not aggravated by service. 38 C.F.R. § 3.304(b) (2013). A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. This includes medical facts and principles that may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306(b) (2013). The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars, absent or poorly functioning parts or organs, will also not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). 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 shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2013). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102 (2013). The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. Factual Background and Analysis I. Lumbar Spine Disorder Service treatment records reflect that in April 1979, he was involved in a motor vehicle accident and was immediately treated afterwards for complaints of low back pain associated with the accident. A June 1979 treatment note referenced X-ray findings of scoliosis of the lumbar spine. It was further indicated that the Veteran reported some pain prior to the accident and increased pain since the accident. A May 1979 narrative summary listed a discharge diagnosis of low back pain and multiple congenital anomalies of the spine on x-ray. A June 1979 health record showed findings of congenital abnormality of the spine as well as back pain secondary to the auto accident. The Veteran was also treated for complaints of low back pain after he slipped and fell from a ladder, striking his lower back on a rung in July 1980. No low back sequelae were noted on separation examination in November 1982. The current clinical evidence indicates that the Veteran has diagnoses of chronic orthopedic disabilities affecting his lumbar spine, which include DDD, DJD, and congenital scoliosis. Post-service private and VA medical records show diagnoses of lumbar DDD and DJD beginning around 1992. Private treatment records dated in 1998 revealed that the Veteran reported a work-related injury in 1992 but was not able to give further information about the incident. A September 2002 VA general medical examination report listed diagnoses of degenerative arthritis of the lumbosacral spine and healed fractures with posttraumatic arthritis at L1 and L5. The Veteran has testified at his hearings before the DRO and the Board that he had onset of his low back pain in service following the documented in-service injuries with continuity of symptomatology ever since. In a September 2005 statement, the Veteran's private physician, J. F. V., M. D., indicated that the Veteran's service treatment records regarding his April 1979 motor vehicle accident and subsequent in-service treatment for low back pain were reviewed. Thereafter, the physician opined that it was as likely as not that the currently diagnosed degenerative disc disease with degenerative joint disease and lumbar spine was directly related to the in-service complaint of back pains. The Board notes that the private physician did not provide a rationale for his September 2005 opinion that the Veteran's lumbar spine disorder was directly related to the in-service complaint of back pains. The Board finds that the September 2005 private physician opinion is of little probative value, as a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). In a March 2007 statement, J. F. V., M. D. noted his review of the Veteran's military records, MRI and CT scan reports, and VA EMG report. Based on the Veteran's work in the engineering department where he was required to do heavy work, including heavy lifting, the physician opined that it was "highly probable/highly possible that between the above injuries/illness and his normal work as a boiler technician (navy) and machinery technician (coastguard), it could have aggravated if not cause certain amount of damage which affected his health primarily for his back, legs, shoulder and hands". Again, the Board has determined that the March 2007 private physician opinion is of little probative value, as the physician did not provide sound reasoning or a clearly articulated conclusion. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes to the probative value to a medical opinion). In a May 2007 VA medical opinion, a VA physician identified as an orthosurgeon consultant noted his review of the service treatment records and claims file. He opined that the Veteran's DJD of the lumbar spine was less likely as not (less than 50/50 probability) caused by or a result of his military service. In his cited rationale, the physician indicated that there was no definite fracture seen on lumbar x-rays during service. He highlighted that an in-service treatment provider made a note of a marked vertical malformation of L1 and could not discern fracture. It was further noted that an in-service diagnosis of acute lower back injury and head laceration injury was given. The VA physician further referenced a May 1979 service record dated one month after the in-service accident, noting that the record stated that the Veteran had lower back pain without any radiation and with vertebral anomalies on x-ray (e.g. hemivertebra L1) and positive bone scan of same area without obvious fracture. The physician then referred to a 2001 CT scan of the thoracolumbar spine that revealed vertebral compression at T12 and hypertrophic degenerative changes of the lumbar spine. The physician indicated that 21 years had passed between the 1979 service record and 2001 CT scan, highlighting that that T12 compression fracture was not seen in 1979 and "most probably may have occurred" after the Veteran's military service. The physician also highlighted that there was no mention of any L1 anomaly on the 2001 CT scan. Based on the foregoing, the physician concluded that the Veteran's DJD of the lumbar spine was less likely as not due to his military service. Records from SSA were associated with the record in February 2009. An April 1999 disability determination listed a primary diagnosis of disorders of back (discogenic and degenerative) and secondary diagnosis of peripheral neuropathy. In the July 2011 remand, the Board found the May 2007 VA medical opinion to be inadequate as the VA physician did not include a discussion of the September 2005 opinion from J. F. V., M. D., and present his opinion within the context of that private physician's opinion. The Board also indicated that the May 2007 VA physician determined, in pertinent part, that the Veteran's lumbar spine disability was not related to military service. While the May 2007 VA physician's opinion was noted to address, in part, why an etiological relationship did not exist, he did not include discussion of the Veteran's congenital lumbar spine scoliosis noted in service and failed to address the question of whether or not the Veteran's pre-existing congenital scoliosis condition was aggravated (permanently worsened beyond its normal natural progression) by military service. On remand, the Board sought to have the VA examiner address the question of whether or not such aggravation of the pre-existing congenital lumbar scoliosis occurred during active duty. Parenthetically, the Board found that the Veteran's scoliosis was clinically described in the record as being a condition that was congenital in nature and thus determined that the condition pre-existed his entry into military service. In an August 2011 VA medical opinion, the same VA physician who authored the May 2007 VA medical opinion again reviewed the claims file. He opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. In his cited rationale, the VA physician acknowledged in-service treatment for low back complaints after the 1979 motor vehicle accident and 1980 ladder fall injury. However, he also highlighted the normal spine findings and notation of no back sequelae in the November 1982 service separation examination, noting that those normal findings taken three years after the 1979 accident and two years after the 1980 injury proved that there were no chronic sequelae from those two accidents. The physician further noted that the Veteran was not diagnosed with degenerative osteoarthritis of the lumbar spine until a decade after discharge. The physician also indicated that no medical evidence was submitted to show that the Veteran's claimed lower back condition manifested to a compensable degree within the initial post-service presumptive period of one year. He commented that the opinion from J. F. V., M. D. provided no rationalization whatsoever to support a nexus or link for the Veteran's current lower back condition to his military service. The physician also opined that the Veteran's 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. In his cited rationale, the VA physician highlighted that service treatment records mentioned multiple congenital anomalies of the spine. He again referenced the normal spine findings and notation of no back sequelae in the November 1982 service separation examination, noting that those normal findings taken three years after the 1979 accident and two years after the 1980 injury proved that there was no aggravation of the congenital anomalies while in service. The physician further indicated that no medical evidence was submitted to show that the Veteran's claimed lower back condition manifested to a compensable degree within the initial post-service presumptive period of one year that would indicate a "true and indumitable aggravation". In this case, post-service VA and private treatment records did reflect findings of current low back disorders. Service treatment records reflected that the Veteran was treated for complaints of low back pain after a motor vehicle accident in 1979 and a fall injury in 1980. However, a finding of a nexus between the Veteran's current low back disorder and in-service events is not shown. In this case, findings of a low back disorder were first shown many years after separation from active service and cannot be presumed to have been incurred during service. The Board also notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The record also includes no competent medical opinion establishing a causal relationship between the post-service treatments for a low back disorder to any established event in service, including in-service motor vehicle accident and fall injuries. In fact, the August 2011 VA examiner specifically opined that the Veteran's condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The August 2011 VA examiner provided a complete rationale for his stated opinions, citing to his review of the claims file and the conflicting evidence of record. As noted above, the Board found the September 2005 and March 2007 private physician opinions to be of little probative value as well as determined the May 2007 VA examiner's medical opinion was inadequate for adjudication purposes. As such, the Board finds that the most persuasive medical evidence that specifically addresses the question of whether the Veteran's present low back disorder was incurred due to events during active service weighs against the claim. Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). In this case, there is competent medical evidence showing a currently diagnosed low back disability manifested by degenerative and/or osteoarthritic changes, but the preponderance of the competent and probative evidence is against finding that there is a link between this disability, which first manifested many years after discharge from service and the Veteran's periods of active service. In this, and in other cases, only competent evidence may be considered to support Board findings. Accordingly, the Board is not free to substitute its own judgment for that of an expert. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The only adequate medical opinion of record concerning the etiology of the Veteran's current low back disability is negative to his claim. The Board will also address whether the Veteran's current low back disabilities are the result of aggravation of his pre-existing congenital lumbar scoliosis by service. As an initial matter, the Board finds that a presumption of soundness does not apply in this case. Evidence of record, including service treatment records and the August 2011 VA medical opinion, clearly noted and acknowledged the existence of a pre-existing or congenital anomalies of the lumbar spine. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.303(c) (2013). Having found clear and unmistakable evidence of a pre-existing low back disorder identified as congenital scoliosis of the lumbar spine or multiple congenital anomalies of the spine, the next inquiry is whether there is clear and unmistakable evidence that congenital anomalies of the spine were aggravated or permanently worsened during service. Here, the Board finds that a preponderance of the evidence is against any finding that the pre-existing congenital anomalies of the spine underwent any permanent increase in symptoms or any increase in severity during service beyond the natural progress of the condition. In fact, the August 2011 VA medical opinion specifically opined that the Veteran's 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. Thus, the presumption of aggravation also does not apply in this case. The Veteran is capable of observing symptoms related to his low back disability and the Board ultimately finds statements from the Veteran in this regard to be competent. See Davidson v. Shinseki, 581 F.3d. 1313, 1315 (Fed. Cir. 2009). Nevertheless, these statements are not competent evidence sufficient to establish the cause of such disability, and the relationship to service, if any. In some cases, lay evidence may be competent and probative evidence of etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson, 581 F.3d at 1315 (finding that, in certain circumstances, lay evidence may be competent to establish a medical etiology). However, medical causation in this case involves questions beyond the range of common experience and common knowledge and requires the special knowledge and experience of a trained physician. The cause of a low back disability cannot be made by the Veteran as a lay person based on mere personal observation, i.e., perceived by visual observation or by any other of the senses. A low back disability, to include DDD and DJD, is not a simple disorder that the Veteran is competent to identify. Therefore, the Veteran's assertions are not competent evidence to establish the cause of his current low back disorder. 38 C.F.R. § 3.159(a)(1) (2013) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). The Board is cognizant that the Veteran's complaints of low back pain were "noted" in service. Under 38 C.F.R. § 3.303(b), continuity of symptomatology is required only where the condition is noted during service is not shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Thus, evidence showing a continuity of symptomatology is contemplated by VA regulations as supporting a claim for service connection for a condition only in a situation where a condition was noted in service but was not determined to be chronic or where there is a question about its chronicity. In this case, the Board finds the Veteran's statements as to continuity of symptomatology are not credible, as they are inconsistent with the other evidence of record. There is no documentary evidence to show that the Veteran received continuous treatment for a low back disorder since service. While the Veteran was treated for low back pain on a few occasions in service, his post-service complaints involving the low back were documented to begin around 1992 at the earliest, many years after his separation from active duty. Although he appears to be sincere in his belief as to service connection, in light of the above discussion, the Veteran's current statements to the effect that he has experienced continuous low back symptomatology since active service are simply not credible or persuasive. The criteria to establish entitlement to service connection for a chronic low back disability, claimed as DDD and DJD of the lumbar spine, have not been established, either through medical or probative lay evidence. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim of entitlement to a chronic low back disability, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). II. Right Wrist Disorder Service treatment records reflect that in July 1980 he received treatment for right wrist complaints and was diagnosed with right wrist strain. No right wrist sequelae were noted on separation examination in November 1982. Post-service medical records show that beginning around 1996, the Veteran was diagnosed with CTS of the right wrist, for which he was treated with several surgeries for carpal tunnel release. Private treatment records dated in January 1997 revealed that the Veteran sustained a work injury in December 1996 followed by numbness and pain in both hands as well as "some feeling of pins and needles in the right hand and right shoulder". In a June 1998 private treatment record, the Veteran indicated that he first developed the onset of tingling in the long and ring fingers in 1994 during vigorous manual activity. A September 2002 VA general medical examination report listed diagnoses of minimal DJD of both wrists and bilateral CTS. The Veteran has testified at his hearings before the DRO and the Board that he had onset of right wrist pain in service with continuity of symptomatology ever since July 1980. In a September 2005 statement, the Veteran's private physician, J. F. V., M.D., indicated that the Veteran's service treatment records regarding his July 1980 treatment for right wrist pain were reviewed. Thereafter, the physician opined that it was as likely as not that the currently diagnosed carpal tunnel syndrome, bilateral wrist, was directly related to the in-service complaints of numbness in hands and wrist pains. The Board notes that the private physician did not provide a rationale for his September 2005 opinion that the Veteran's right wrist disorder was directly related to the in-service complaints of numbness in hands and wrist pains. The Board again notes that the September 2005 private physician opinion is of little probative value, as a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). In a March 2007 statement, the Veteran's private physician, J. F. V., M. D., noted his review of the Veteran's military records, MRI and CT scan reports, and VA EMG report. Based on the Veteran's work in the engineering department where he was required to do heavy work, including heavy lifting, the physician opined that it was "highly probable/highly possible that between the above injuries/illness and his normal work as a boiler technician (navy) and machinery technician (coastguard), it could have aggravated if not cause certain amount of damage which affected his health primarily for his back, legs, shoulder and hands". As noted above, the Board has determined that the March 2007 private physician opinion is of little probative value, as the private physician did not provide sound reasoning or a clearly articulated conclusion. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes to the probative value to a medical opinion). In a May 2007 VA medical opinion, a VA physician identified as an orthosurgeon consultant noted his review of the service treatment records and claims file. He opined that the Veteran's CTS of both wrists was "not caused by or result of military service". In his stated rationale, the physician indicated that the only medical record found was a July 1980 entry of right hand pain and superficial laceration of the right upper arm. The physician indicated that the entry did not in any way favor a CTS manifestation back in service. Thus, the physician concluded that CTS of both wrists were not caused or a result of his military service. In the July 2011 remand, the Board found the May 2007 VA medical opinion to be inadequate as the VA physician did not include a discussion of the September 2005 nexus opinion from J. F. V., M. D., and present his opinion within the context of that private physician's opinion. In an August 2011 VA medical opinion, the same VA physician who authored the May 2007 VA medical opinion again reviewed the claims file, to include the medical opinion/certificates of J. F. V., M. D. He opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. In his cited rationale, the VA physician referenced the sole in-service treatment pertaining to the right wrist in 1980, highlighting that there were no further treatment records or medical consults regarding the right wrist during service. He then pointed to the normal physical findings of the upper extremities in the Veteran's November 1982 service separation examination, noting that right wrist symptoms in service were acute as well as adequately treated and that no chronic sequalae developed. The VA physician further indicated that no medical evidence was submitted to show that the Veteran's claimed right wrist condition manifested to a compensable degree within the initial post-service presumptive period of one year. Post-service VA and private treatment records did reflect findings of current right wrist disorders, including CTS and DJD. Service treatment records showed that the Veteran was treated for complaints of right wrist pain and assessed to have right wrist strain on an isolated occasion in 1980. However, a finding of a nexus between the Veteran's current right wrist disorder and in-service events is not shown. In this case, findings of right wrist disorder were first shown around 1996 many years after separation from active service. The Board also notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The record also includes no competent medical opinion establishing a causal relationship between the post-service treatments for right wrist disorders and any established event in service, including the isolated incidence of in-service treatment for wrist pain and strain in 1980. In fact, the August 2011 VA examiner specifically opined that the Veteran's claimed right wrist disorder less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The August 2011 VA examiner provided a complete rationale for his stated opinions, citing to his review of the claims file and the conflicting evidence of record. As noted above, the Board found the September 2005 and March 2007 private physician opinions to be of little probative value as well as determined the May 2007 VA examiner's medical opinion was inadequate for adjudication purposes. As such, the Board finds that the most persuasive medical evidence that specifically addresses the question of whether the Veteran's present right wrist disorder was incurred due to events during active service weighs against the claim. Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). In this case, there is competent medical evidence showing a currently diagnosed right wrist disability manifested by degenerative osteoarthritic changes or DJD, but the preponderance of the competent and probative evidence is against finding that there is a link between this disability, which first manifested many years after discharge from service and the Veteran's periods of active service. The Board also acknowledges the Veteran's contentions that he has current residuals of a right wrist injury sustained in service. Although the Veteran might sincerely believe that a current disorder is related to events during service, as a layperson, his statements in this particular case are not competent evidence regarding the etiology of the currently diagnosed right wrist disorder. See Barr, 21 Vet. App. at 307 (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). In this regard, the Board notes that 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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (lay witness capable of diagnosing dislocated shoulder). Competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Barr v. Nicholson, 21 Vet App 303 (2007) (lay testimony is competent to establish the presence of varicose veins); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). However, unlike the varicose veins in Barr or dislocated shoulder in Jandreau, whether there are any current residuals of an injury to the right wrist in service is not a matter capable of lay diagnosis in this case. Davidson, 581 F.3d 1313; Buchanan, 451 F.3d 1331; Jandreau, 492 F.3d 1372. Therefore, the Veteran's statements about an injury to the wrist in service constitute competent evidence. However, he is not competent to offer an opinion that such an injury has resulted in his current right wrist disability of CTS and/or DJD. The Board is cognizant that the Veteran's complaints of right wrist pain and treatment for right wrist strain were "noted" in service. The Board finds the Veteran's statements as to continuity of symptomatology are not credible, as they are inconsistent with the other evidence of record. There is no documentary evidence to show that the Veteran received continuous treatment for any right wrist disorder since service. While the Veteran was treated for right wrist complaints in 1980 in service, his post-service complaints involving the right wrist were documented to begin around 1996 at the earliest, many years after his separation from active duty. Although he appears to be sincere in his belief as to service connection, in light of the above discussion, the Veteran's current statements to the effect that he has experienced continuous right wrist symptomatology since active service are simply not credible or persuasive. In light of the record discussed above, the criteria to establish entitlement to service connection for a right wrist disorder have not been met, either through medical or lay evidence. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for a chronic low back disability, claimed as DDD and DJD of the lumbar spine, is denied. Entitlement to service connection for a right wrist disorder, to include CTS and DJD of the right wrist, is denied. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs