Citation Nr: 1334532 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 10-08 446 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for chronic sinusitis. 4. Entitlement to service connection for arthritis of the neck, to include as secondary to a service-connected disability. 5. Entitlement to service connection for bilateral knee arthritis, to include as secondary to a service-connected disability. 6. Entitlement to service connection for bilateral arm arthritis, to include as secondary to a service-connected disability. 7. Entitlement to service connection for bilateral shoulder arthritis, to include as secondary to a service-connected disability. 8. Entitlement to service connection for bilateral ankle arthritis, to include as secondary to a service-connected disability. 9. Entitlement to service connection for bilateral neuropathy/radiculopathy, to include as secondary to a service-connected disability. 10. Entitlement to a rating in excess of 10 percent for chronic vascular headaches. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. L. Douglas, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from February 1968 to January 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions in August 2009, February 2010, and July 2010 by the Louisville, Kentucky, Regional Office (RO) of the Department of Veterans Affairs (VA). The issue of entitlement to a rating in excess of 10 percent for chronic vascular headaches is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A bilateral hearing loss disability was not manifest during active service or within the first post-service year and is not shown to have developed as a result of an established event, injury, or disease during active service. 2. Tinnitus was not manifest during active service or within the first post-service year and is not shown to have developed as a result of an established event, injury, or disease during active service. 3. Chronic sinusitis was not manifest during active service and is not shown to have developed as a result of an established event, injury, or disease during active service. 4. Arthritis of the neck was not manifest during active service or within the first post-service year, is not shown to have developed as a result of an established event, injury, or disease during active service, and is not shown to have been proximately due to a service-connected disability. 5. Bilateral knee arthritis was not manifest during active service or within the first post-service year, is not shown to have developed as a result of an established event, injury, or disease during active service, and is not shown to have been proximately due to a service-connected disability. 6. Bilateral arm arthritis was not manifest during active service or within the first post-service year, is not shown to have developed as a result of an established event, injury, or disease during active service, and is not shown to have been proximately due to a service-connected disability. 7. Bilateral shoulder arthritis was not manifest during active service or within the first post-service year, is not shown to have developed as a result of an established event, injury, or disease during active service, and is not shown to have been proximately due to a service-connected disability. 8. Bilateral ankle arthritis was not manifest during active service or within the first post-service year, is not shown to have developed as a result of an established event, injury, or disease during active service, and is not shown to have been proximately due to a service-connected disability. 9. Bilateral neuropathy/radiculopathy was not manifest during active service or within the first post-service year, is not shown to have developed as a result of an established event, injury, or disease during active service, and is not shown to have been proximately due to a service-connected disability. CONCLUSIONS OF LAW 1. Bilateral hearing loss was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2012). 2. Tinnitus was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. Chronic sinusitis was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 4. Arthritis of the neck was not incurred in or aggravated by military service nor may service connection be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 5. Bilateral knee arthritis was not incurred in or aggravated by military service nor may service connection be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 6. Bilateral arm arthritis was not incurred in or aggravated by military service nor may service connection be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 7. Bilateral shoulder arthritis was not incurred in or aggravated by military service nor may service connection be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 8. Bilateral ankle arthritis was not incurred in or aggravated by military service nor may service connection be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 9. Bilateral neuropathy/radiculopathy was not incurred in or aggravated by military service nor may service connection be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The Veteran was notified of the duties to assist and of the information and evidence necessary to substantiate his claims by correspondence dated in July 2008 and November 2009. The notice requirements pertinent to the issues addressed in this decision have been met and all identified and authorized records relevant to these matters have been requested or obtained. The available record includes service medical records, VA treatment and examination reports, private treatment records, an August 2009 private medical opinion, and statements from the Veteran, his spouse, and his son in support of his claims. VA efforts to obtain records of additional private treatment identified by the Veteran by authorization forms VA 21-4142 dated in May 2008 were unsuccessful. The Veteran was notified in October 2009 of the specific records VA was unable to obtain, of the efforts made to obtain those records, of the further action to be taken by VA with respect to the claims, and that he was ultimately responsible for providing the evidence. There is no evidence of any additional existing pertinent records. The Board finds that further attempts to obtain additional evidence would be futile. When VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate. VA regulations provide that a medical examination or medical opinion is necessary if the record does not contain sufficient competent medical evidence to decide the claim, but includes competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of disability, establishes that the veteran suffered an event, injury, or disease in service, or has a disease or symptoms of a disease manifest during an applicable presumptive period, and indicates the claimed disability or symptoms may be associated with the established event, injury, or disease. 38 C.F.R. § 3.159(c)(4). The types of evidence that "indicate" that a current disability "may be associated" with military service include credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). VA, however, is not required to provide a medical examination when there is no credible evidence establishing an event, injury, or disease in service. Bardwell v. Shinseki, 24 Vet. App. 36 (2010). The Board finds that the available record includes no present diagnosis or manifest symptoms of sinusitis related to service and that the Veteran has not identified an event, injury, or disease nor treatment or symptom manifestations of sinusitis during active. There is no reasonable possibility that a present examination could substantiate the Veteran's sinusitis claim in the absence of an established event in service and a VA examination or medical opinion as to this claim was not required. VA medical opinions obtained concerning the other service connection issues on appeal are adequate as they are predicated on a substantial review of the record and medical findings and consider the Veteran's complaints and symptoms. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion as to these issues has been met. 38 C.F.R. § 3.159(c)(4) (2012). The available medical evidence is sufficient for adequate determinations. There has been substantial compliance with all pertinent VA law and regulations and to adjudicate the claims would not cause any prejudice to the appellant. Service Connection Service connection may be granted for a disability resulting from injury suffered or disease contracted in line of duty or for aggravation of preexisting injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Where a veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of the veteran's service as shown by the veteran's service record, the official history of each organization in which the veteran served, the veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). Service connection may also 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) (2012). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either proximately caused by or proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection can be granted for certain chronic diseases if manifest to a degree of 10 percent or more within one year of separation from active service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Sensorineural hearing loss and arthritis are chronic diseases for presumptive service connection purposes. 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. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when 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) (2012). Continuity of symptomatology applies to those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The United States Court of Appeals for Veterans Claims (hereinafter "the Court"), however, has held that even though a disease is not included on the list of presumptive diseases a nexus between the disease and service may nevertheless be established on the basis of direct service connection. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that when a claimed disorder is not included as a presumptive disorder direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In order to prevail on the issue of service connection on the merits, there must be medical evidence of (1) a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). The Federal Circuit has held that a veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Medical evidence is required to demonstrate a relationship between a current disability and the continuity of symptomatology demonstrated if the condition is not one where a lay person's observations would be competent. Clyburn v. West, 12 Vet. App. 296 (1999). Whether lay evidence is competent and sufficient in a particular case is an issue of fact and lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (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 (Fed. Cir. 2007) Lay evidence presented by a veteran concerning his continuity of symptoms after service may generally be considered credible and ultimately competent, regardless of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (2006). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). A hearing loss disability for VA compensation purposes is defined by regulation and impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385 (2012). Once the requirements of 38 C.F.R. § 3.385 (2012) have been met and a present hearing "disability" under applicable VA laws and regulations is found, a determination must be made as to whether the current hearing disorder is related to service. In particular, the Court has held that 38 C.F.R. § 3.385 operates to establish when a measured hearing loss is, or is not, a "disability" for which compensation may be paid, provided that the requirements for service connection are otherwise met. Hensley v. Brown, 5 Vet. App. 155 (1993) (citing CURRENT MEDICAL DIAGNOSIS & TREATMENT 110-11 (Stephen A. Schroeder et. al. eds., 1988). Even if a veteran does not have a hearing loss disability for VA compensation purposes recorded during service, service connection may still be established if post-service evidence satisfies the criteria of 38 C.F.R. § 3.385 and the evidence links the present hearing loss to active military service. Id. at 158. The threshold for normal hearing is 0 to 20 decibels. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 3.102 (2012). Hearing Loss and Tinnitus The pertinent evidence of record shows that on the Veteran's pre-induction audiological evaluation in November 1967, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 15 15 15 LEFT 15 10 15 20 35 Service treatment records are negative for complaint, diagnosis, or treatment for hearing loss or tinnitus. The Veteran's service discharge report, DD 214, noted his military occupational specialty was field radio mechanic. In his November 1969 report of medical history the Veteran denied having or having ever had hearing loss or ear trouble. Separation examination in November 1969 revealed a normal clinical evaluation of the ears. On audiological evaluation upon separation examination in November 1969, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 30 20 --- 20 LEFT 30 20 15 --- 20 In his June 2008 application for VA benefits the Veteran, among other things, asserted that service connection was warranted for bilateral hearing loss and tinnitus. He identified no date for the onset of any disability or treatment. VA treatment records dated in January 2009 noted the Veteran complained of decreased hearing over the past few years and bilateral tinnitus that had been "present for quite awhile." He reported military noise exposure as a field radio operator and post-service noise exposure as an auctioneer. Air conduction studies revealed a mild, bilateral sensory hearing loss. VA audiology examination in June 2009 noted the Veteran reported exposure to weapons noise and equipment and power tool noise in service and exposure to noise as a forklift driver at a saw mill from 1970 to 1973, He reported he had worked as an auctioneer and real estate broker for the majority of his life. He stated he had noticed intermittent ringing in the ears for the past four to five years. On the authorized audiological evaluation in June 2009, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 30 35 LEFT 10 15 20 30 30 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 96 percent in the left ear. The examiner found it was less likely the Veteran's hearing loss and tinnitus were caused by or the result of military noise exposure. It was noted that a review of induction and separation evaluations revealed a clinically significant shift in the right ear at 1000 Hertz and in the left ear at 500 Hertz, but that there was no evidence of low frequency hearing loss and the cause of the low frequency shift at discharge had apparently resolved. The examiner found that the evidence indicated the Veteran's hearing was not permanently damaged while he was in the service. Based upon the evidence of record, the Board finds that bilateral hearing loss and tinnitus were not manifest during active service, were not manifest within the first post-service year, and are not shown to have developed as a result of an established event, injury, or disease during active service. Although the Veteran's report of military noise exposure is consistent with the circumstances if his service, the June 2010 VA audiology opinion is persuasive that his present hearing loss and tinnitus were not caused by or the result of military noise exposure. The examiner is shown to have considered the Veteran's reports of noise exposure during and after service, to have considered all of the evidence of record, and to have provided adequate rationale for the etiology opinions provided. The examiner also provided an adequate explanation concerning the shifts shown on service department audiology evaluations upon separation based upon a thorough review of the record and the current audiology findings. The Board further finds that the Veteran is competent to provide evidence as to observations and some medical matters, but that his statements are, at most, conclusory assertions of a nexus between hearing loss and tinnitus manifest after service and noise exposure in service. Jandreau, 492 F.3d 1372; Buchanan, 451 F.3d 1331. As questions of medical diagnosis and a relationship to service are complex etiological questions akin to the type of medical matters which laypersons are not competent to provide, his statements are insufficient to establish service connection. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (Board must determine whether claimed disability is type of disability for which lay person is competent to provide etiology or nexus evidence). Therefore, the claims for entitlement to service connection for hearing loss and tinnitus must be denied. Sinusitis Service treatment records are negative for complaint, diagnosis, or treatment for sinusitis. In his November 1969 report of medical history the Veteran denied having or having ever had sinusitis. Separation examination in November 1969 revealed a normal clinical evaluation of the sinuses. VA treatment records include a June 2001 VA otolaryngology clinic screening report noting there was no evidence of sinusitis. Private treatment records dated in February 2006 and April 2008 noted examinations revealed the Veteran's sinuses were not tender, red, or swollen. In his June 2008 application for VA benefits the Veteran, among other things, asserted that service connection was warranted for bilateral hearing loss and tinnitus, chronic sinusitis. He identified no date for the onset of any disability or treatment. Based upon the evidence of record, the Board finds that sinusitis was not manifest during active service and is not shown to have developed as a result of an established event, injury, or disease during active service. The Veteran has provided no information as to any symptoms of sinusitis during active service and there is no evidence of any present sinusitis related to an injury, disease, or event during active service. The Board further finds that sinusitis is a disorder for which some degree of medical expertise is required for opinions as to diagnosis and etiology. The Veteran is not competent to provide such opinions. The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Brown, 3 Vet. App. 223, 225 (1992). Therefore, the claim for entitlement to service connection for sinusitis is denied. Arthritis and Neuropathy/Radiculopathy The pertinent evidence of record shows that a verified postural back strain was noted upon the Veteran's pre-induction examination in November 1967. The Veteran. however, was found fit for military service. Service treatment records are negative for complaint, diagnosis, or treatment for arthritis, neuropathy, or radiculopathy. Treatment records show his duties during service included carpentry work and that he received treatment for low back pain without radicular symptoms. In his November 1969 report of medical history the Veteran denied having or having ever had arthritis or neuritis. Separation examination in November 1969 revealed normal clinical evaluations of the upper extremities, lower extremities, and neurologic system. VA treatment records dated in February 2001 noted the Veteran complained of a four year history of neck, back, hand, knee, and ankle pain. A subsequent February 2001 report noted arthritis at several joints per X-ray studies. An April 2001 report noted that testing revealed a negative rheumatoid factor and that X-ray examinations of the cervical, thoracic, and lumbar spines were suggestive of DISH (diffuse idiopathic skeletal hyperostosis). X-ray examination of the lumbar spine in February 2006 revealed mild scoliosis convex to the right, findings in the lower thoracic and upper lumbar spine consistent with DISH, moderate degenerative disease at L3-4 and L4-5, and marked degenerative disc disease at L5-S1. A VA active problems list printed in July 2008 noted a diagnosis of unspecified osteoarthritis was established in February 2006. Private treatment records dated in February 2006 and April 2008 noted examination revealed the Veteran's sinuses were not tender, red, or swollen. The diagnoses included generalized osteoarthritis involving multiple sites. In his June 2008 application for VA benefits the Veteran, among other things, asserted that service connection was warranted for arthritis of the neck, knees, arms, shoulders, and ankles. He identified no date for the onset of any disability or treatment, but indicated he had received treatment for arthritis at "Lanstool Hospital, Germany." On VA spine examination in June 2009 the Veteran reported the onset of neck and back pain during basic training and that heavy lifting during service in Germany had caused neck and back pain. The diagnoses included DISH, degenerative disc disease of the cervical spine, and degenerative disc disease of the lumbosacral spine. The examiner found the Veteran's DISH was not manifest upon X-ray examination during service and that it was a slowly developing chronic disorder likely arising some time after service. The continuity of symptoms, however, suggested that the disease process giving rise to his current degenerative disc disease of the lumbosacral spine did begin in the mid to late 1960's and, in part, preceded service. The examiner found that it was at least as likely as not that degenerative disc disease of the lumbosacral spine was permanently aggravated by military service. In an August 2009 private medical statement S.K.B., M.D., noted the Veteran had degenerative disk disease of the lumbosacral spine and arthritis in the cervical spine, knees, ankles, shoulders, and arms. It was further noted that "[t]he arthritis is as related to his service time as the degenerative disk disease of his lumbosacral spine due to the conditions he was required to serve in." In his August 2009 notice of disagreement the Veteran asserted that his arthritis of the neck, knees, arms, shoulders, and ankles were related to arthritis associated with his service-connected degenerative disc disease of the lumbosacral spine. In a November 2009 statement the Veteran's spouse recalled that while serving in Germany he had complained about joint pain over most of his body, including to the neck, knees, ankles, and shoulders. She stated that his joint pain continued and had been more frequent. The Veteran's son also provided a statement in November 2009 recalled that he had almost daily problems with pain in the head, neck/spine, and shoulders "for as long as [he] could remember." It was noted that over the past 10 to 15 years he had increasingly chronic problems with his joints and on days when the weather changed he was near incapacitation. It was further noted that his father had been "one of the hardest working men [he had] ever known" and that his current arthritis made it difficult for him to do any sort of manual labor. Private chiropractic treatment records dated in November 2009 noted an orthopedic evaluation revealed a lumbar lesion/double leg raise test was positive, a sciatic nerve lesion/Lasegue (straight leg raise) test was positive bilaterally, and an intervertebral disc syndrome/Milgrams test was positive. The assessment/diagnosis included degenerative spinal discs and arthritis to the cervical and lumbar spine. On VA examination in February 2010 the Veteran reported vague and diffuse complaints to the bilateral shoulders, ankles, and knees which he believed were related to his back disability. He reported the onset of symptoms in the 1970's and 1980's. The examiner noted X-ray studies revealed mild degenerative changes to the knees, right slightly more pronounced that the left, mild degenerative changes to the right and left shoulders, suspected remote trauma to the right distal tibia with mild degenerative changes at the ankle, a well maintained left ankle for age with calcaneal spur formation, and moderate degenerative changes of the cervical spine that were most pronounced at the C5-C6 and C6-C7 levels. The examiner, however, found that there was no evidence of a neck injury during active service and that there was no evidence supporting a secondary connection between a lumbar spine condition and the Veteran's arthritis of the neck, ankles, knees, wrists, and shoulders. On VA examination in June 2010 the Veteran reported the gradual onset of leg numbness approximately ten years earlier and current symptoms of pain, numbness, and tingling that were persistent. An electromyography (EMG) study was performed in July 2010 that revealed no electrodiagnostic evidence of right lumbar radiculopathy in the muscles and nerves. It was suspected that the Veteran had a possible sensorimotor polyneuropathy (primary demyelinating). The examiner's diagnosis was sensorimotor polyneuropathy to the bilateral lower extremities. It was noted that current EMG testing did not disclose a radiculopathy that could be related to a distal leg neuropathy or radiculopathy and that the Veteran's sensorimotor polyneuropathy was related to the peripheral nerves and not the more central nerves associated with degenerative disc disease of the lumbosacral spine. A bilateral neuropathy/radiculopathy of the lower extremities were found not to be caused by or a result of service-connected degenerative disc disease of the lumbosacral spine. Private chiropractic treatment records dated in June 2010 noted diagnoses including severe degeneration of the lumbar or lumbosacral intervertebral disc. An August 2010 opinion found the Veteran had lower extremity radiculopathy due to degenerative disc disease, facet hypertrophy, and lumbar spine osteophytosis creating encroachment upon the lumbar spinal nerve roots. Based upon the evidence of record, the Board finds that arthritis of the neck, knees, arms, shoulders, and ankles and bilateral neuropathy/radiculopathy were not manifest during active service; that arthritis of the neck, knees, arms, shoulders, and ankles was not manifest within the first post-service year; that arthritis of the neck, knees, arms, shoulders, and ankles and bilateral neuropathy/radiculopathy are not shown to have developed as a result of an established event, injury, or disease during active service; and that arthritis of the neck, knees, arms, shoulders, and ankles and bilateral neuropathy/radiculopathy are not shown to have been proximately due to a service-connected disability. The February 2010 and June 2010 VA medical opinions are found to be persuasive in this case. The opinions are shown to have been based upon thorough examinations, thorough reviews of the evidence of record, and adequate consideration of the evidence of record. Although in a November 2009 statement the Veteran's spouse reported that while serving in Germany during active service the Veteran had complained of joint pain over most of his body, the Board finds that to the extent this statement may be construed either as an opinion that arthritis was manifest in service or that the present post-service diagnoses of arthritis are etiologically related to symptoms manifest in service it is not credible. Diagnoses and etiology opinion concerning arthritis are complex medical matters and the Veteran's spouse is not shown to have the acquired medical expertise necessary to provide competent evidence as to such matters. The report of joint pains over most of the Veteran's body during active service and the Veteran's own report of having received treatment for arthritis in Germany are found to be inconsistent with the contemporary medical records associated with his service. These specific statements are found to be not credible due to inconsistency with the other evidence of record and due to the interests of the Veteran and his spouse in the outcome of the claims. In fact, VA treatment records dated in February 2001 show the Veteran reported only a four year history of neck, back, hand, knee, and ankle pain and the earliest medical report of arthritis to several joints was provided by reference to X-ray studies dated in February 2001. There is no competent and credible evidence of arthritis manifested during service nor within the first post-service year. In determining whether evidence submitted by a veteran is credible VA may consider internal consistency, facial plausibility, and consistency with other evidence. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (superseded by statute for an unrelated point of law as stated by Duenas v. Principi, 18 Vet. App. 512 (2004)); see also Buchanan, 451 F.3d at 1337 (VA can consider bias in lay evidence and conflicting statements of the veteran in weighing credibility); Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). The Court has held that VA is free to favor one medical opinion over another provided it offers an adequate basis for doing so. See Owens v. Brown, 7 Vet. App. 429 (1995). The Court has also held that "[Doctors'] diagnoses can be no better than the facts alleged by appellant." Swann v. Brown, 5 Vet. App. 229, 233 (1993) The Board notes that in an August 2009 private medical statement Dr. S.K.B. noted the Veteran had degenerative disk disease of the lumbosacral spine and arthritis in the cervical spine, knees, ankles, shoulders, and arms. It was noted that "[t]he arthritis is as related to his service time as the degenerative disk disease of his lumbosacral spine due to the conditions he was required to serve in." No rationale for this opinion, however, was provided and the physician is not shown to have reviewed the pertinent evidence of record associated with these claims. The Board finds that, while competent, the August 2009 etiology opinion as to the relationship between arthritis of the neck, knees, ankles, shoulders, and arms warrants a lesser degree of probative weight. The opinion is found to be somewhat equivocal as to the nexus to service and is not shown to have considered the evidence indicating treatment in service for aggravation of a pre-existing low back injury and the absence of any contemporaneous evidence of specific complaints or injuries to the neck, knees, ankles, shoulders, and arms in service. It is also unclear what "conditions" the physician may have considered as the basis of the arthritis nexus opinion, but that a review of the available evidence does not reveal any established events, injuries, or diseases in service associated with the claimed joints that could be reasonably construed as related to the post-service diagnoses of arthritis. Therefore, the opinion of the February 2010 VA examiner is persuasive that there was no evidence of a neck injury, nor any event associated with arthritis of the neck, knees, ankles, shoulders, and arms, during active service and that there was no evidence supporting a secondary connection between the Veteran's service-connected lumbar spine disability and his present arthritis of the neck, ankles, knees, arms, and shoulders. The Board also notes that private chiropractic treatment records dated in November 2009, June 2010, and August 2010 include evidence in support of the Veteran's claim for entitlement to service connection for bilateral neuropathy/radiculopathy, to include as secondary to his service-connected degenerative disc disease of the lumbosacral spine. The August 2010 opinion specifically found the Veteran had lower extremity radiculopathy due to degenerative disc disease, facet hypertrophy, and lumbar spine osteophytosis creating encroachment upon the lumbar spinal nerve roots. The evidence also indicates the Veteran received treatment over this period of time from these treatment providers. The medical findings and etiology opinions are found to be competent and credible. The Board finds, however, that the opinions of the June 2010 are persuasive that bilateral neuropathy/radiculopathy was neither incurred during or as a result of an event, injury, or disease in service, nor to have been incurred or aggravated as a result of his service-connected degenerative disc disease of the lumbosacral spine. It is significant to note that upon VA examination in June 2010 the Veteran reported the gradual onset of leg numbness approximately ten years earlier and that an EMG study in July 2010 that revealed no electrodiagnostic evidence of right lumbar radiculopathy. The examiner noted it was suspected that the Veteran had a possible sensorimotor polyneuropathy (primary demyelinating) and the diagnosis provided was sensorimotor polyneuropathy to the bilateral lower extremities. The examiner found bilateral neuropathy/radiculopathy of the lower extremities were not caused by or a result of service-connected degenerative disc disease of the lumbosacral spine and provided a thorough explanation for the opinions based upon the current EMG findings. As the November 2009, June 2010, and August 2010 private chiropractic treatment findings and etiology opinions are not shown to have included EMG or other similar diagnostic neurological testing, the Board finds the June 2010 VA opinions are persuasive. The Board also notes that "the Court has expressly declined to adopt a 'treating physician rule' which would afford greater weight to the opinion of a veteran's treating physician over the opinion of a VA or other physician." Winsett v. West, 11 Vet. App. 420, 424-25 (1998) (citing Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Williams v. Brown, 4 Vet. App. 270, 273 (1993) ("Nowhere is it provided in law or regulation that opinions by the examining psychiatrists are inherently more persuasive than that of other competent mental health professionals."). The Court has held, however, that "[a] private medical opinion may not be discounted solely because the opining physician did not review the claims file." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Further, "the Board may not prefer a VA medical opinion over a private medical opinion solely because the VA examiner reviewed the claims file." Id. The level of training, education, and experience of the person conducting the examination is a factor that, if the Board affords more or less weight to the report because of that reason, must be thoroughly explained in its decision. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996)). The Board finds the opinions of the February 2010 and June 2010 VA examiners are persuasive in this case for the reasons stated and the demonstrated thoroughness of the evidence reviews and provided rationale for the provided opinions. Therefore, the claims for entitlement to service connection must be denied. The preponderance of the evidence in this case is against the Veteran's service connection claims. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for chronic sinusitis is denied. Entitlement to service connection for arthritis of the neck, to include as secondary to a service-connected disability, is denied. Entitlement to service connection for bilateral knee arthritis, to include as secondary to a service-connected disability, is denied. Entitlement to service connection for bilateral arm arthritis, to include as secondary to a service-connected disability, is denied. Entitlement to service connection for bilateral shoulder arthritis, to include as secondary to a service-connected disability, is denied. Entitlement to service connection for bilateral ankle arthritis, to include as secondary to a service-connected disability, is denied. Entitlement to service connection for bilateral neuropathy/radiculopathy, to include as secondary to a service-connected disability, is denied. REMAND A review of the evidence of record shows that conflicting medical opinions have been provided as to etiology and manifest nature of the Veteran's headaches over the course of this appeal. The Board notes that service connection was established for chronic vascular headaches in a February 2010 rating decision based upon the findings of a February 2010 VA examination indicating the Veteran's headaches at that time were associated with his treatment for headaches in service and which were not caused by his service-connected degenerative disc disease of the lumbosacral spine. The subsequent evidence of record, however, includes the Veteran's report of headaches associated with his neck disorder and an August 2010 private chiropractor's opinion attributing his cervicogenic headaches to cervical and thoracic spine disorders. It is also significant to note that VA examination and EMG studies in June 2010 and July 2010 revealed a possible sensorimotor polyneuropathy (primary demyelinating) and that a March 2011 VA examiner noted the Veteran's current headache disorder diagnoses included cervicalgia and myofascial pain with no post-service evidence for vascular headaches. It was further noted he had classic muscle contraction headaches which were as likely as not related to his cervical spine degenerative disc disease. In light of the conflicting medical opinions as to the as to etiology and manifest nature of the Veteran's headaches over the course of this appeal, the Board finds additional development is required prior to appellate review. VA's duty to assist requires reasonable efforts to assist claimants in obtaining evidence necessary to substantiate a claim and in claims for disability compensation requires that VA provide medical examinations or obtain medical opinions when necessary for an adequate decision. 38 C.F.R. § 3.159 (2012). VA has a duty to assist the veteran which includes conducting a thorough and contemporaneous medical examination. See Hyder v. Derwinski, 1 Vet. App. 221 (1991); Green v. Derwinski, 1 Vet. App. 121, 124 (1991); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991) (where the record does not adequately reveal the current state of the claimant's disability, a VA examination must be conducted). Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran provide the names, addresses, and approximate dates of treatment of all medical care providers, VA and non-VA, who provided any treatment pertinent to the issue remaining on appeal. After the Veteran has signed the appropriate releases, any indicated records should be obtained and associated with the claims folder. Appropriate efforts must be taken to obtain all pertinent VA treatment records, unless further efforts would be futile. All attempts to procure records should be documented in the file. If any records identified by the Veteran cannot be obtained he should be provided a notice to (a) identify the specific records VA is unable to obtain; (b) briefly explain the efforts made to obtain those records; (c) describe any further action to be taken by VA with respect to the claims; and (d) explain that he is ultimately responsible for providing the evidence. 2. Schedule the Veteran for a VA examination by an appropriate medical specialist for an opinion as to the nature and severity of his service-connected chronic vascular headaches. All indicated examinations, tests, or studies necessary for an adequate opinion should be conducted. The examiner must address whether any electrodiagnostic testing, such as an EMG study, is indicated for an adequate determination as to the severity and frequency of any vascular headache symptoms manifest during the course of this appeal and to distinguish chronic vascular headaches from any manifest headache symptoms during this period attributable to a nonservice-connected disability (such as degenerative changes of the cervical spine, sensorimotor polyneuropathy, or a primary demyelinating disorder). Opinions should be provided based on the results of any additional examinations or studies, a review of the medical evidence of record, and sound medical principles. All examination findings, with the complete rationale for all opinions expressed, should be set forth in the examination report. 3. After completion of the above and any additional development deemed necessary, the issue remaining on appeal should be reviewed with consideration of all the evidence of record. If any benefit sought remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and should be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review of all issues for which an appeal has been perfected, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs