Citation Nr: 1335313 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 09-07 643 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Entitlement to service connection for hypertension on a direct and presumptive basis. 2. Entitlement to service connection for a low back disorder. 3. Entitlement to service connection for a bilateral knee disorder. 4. Entitlement to service connection for a left hand disorder. 5. Entitlement to service connection for hypertension, claimed as secondary to service-connected anxiety. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran, who is the appellant in this case, had verified active service from July 1962 to May 1965. He also had verified service in the Army Reserves from May 1965 to July 1968 and verified service in the Naval Reserves from April 1977 to May 1978. The Veteran also claims to have had service in the Naval Reserve from 1976 to 1982, the Army National Guard from 1982 to 1991, and service in the Rhode Island National Guard, periods which have been unverified. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2008 and August 2011 rating determinations of the Department of Veterans Affairs (VA) Regional Office (RO) located in Providence, Rhode Island. In the June 2008 rating determination, the RO denied service connection for back, knee, and left hand disorders. In the August 2011 rating determination, the RO denied service connection for hypertension on a direct and presumptive basis. The Veteran appeared and gave testimony at a hearing before a local hearing officer in July 2012 and at a Board videoconference before the undersigned Veterans Law Judge in June 2013. Transcripts of both hearings are of record. As will be explained below, given the findings below as to the Veteran's claim for service connection for hypertension, because there is sufficient competent lay and medical evidence to decide the theory of direct service and presumptive connection, and to avoid unnecessary delay in adjudicating these theories because of a newly advanced secondary service connection theory (38 C.F.R. § 3.310 (2013)), the Board is bifurcating the issue into two separate issues - of entitlement to service connection for a hypertension on a direct basis and presumptive basis and entitlement to service connection for hypertension as secondary to the service-connected anxiety disorder. The case has been recharacterized as set forth in the title page above. Tyrues v. Shinseki, No. 2013-7007, 2013 WL XXXXXXX, at *Y (Fed. Cir. Oct. 10, 2013). The claims of service connection for hypertension as secondary to service-connected anxiety disorder and service connection for a left hand disorder are remanded to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. There was no cardiovascular disease or injury during service. 2. Hypertension did not begin during active service or for many years after service nor did it have its onset during a period of ACDUTRA or INACDUTRA. 3. Symptoms of hypertension were not chronic in service. 4. Symptoms of hypertension were not continuous since service. 5. Hypertension did not manifest to 10 percent within one year of service separation. 6. Currently diagnosed hypertension is not related to service. 7. The Veteran did not sustain an injury or disease of the low back during active service. 8. The Veteran did not experience chronic symptoms of a low back disorder during active service. 9. The Veteran did not experience continuous symptoms of a low back disorder after active service. 10. Lumbar spine arthritis did not manifest to 10 percent within one of service separation. 11. Currently diagnosed lumbar spine arthritis is not related to service. 12. The Veteran did not sustain an injury or disease of the knees during active service. 13. The Veteran did not experience chronic symptoms of a bilateral knee disorder during active service. 14. The Veteran did not experience continuous symptoms of a bilateral knee disorder after active service. 15. Degenerative joint disease of the knees did not manifest to 10 percent within one of service separation. 16. Currently diagnosed degenerative joint disease of the knees is not related to service. CONCLUSIONS OF LAW 1. Hypertension was not incurred or aggravated by active service or during a period of ACDUTRA or INACDUTRA, nor may it be presumed to have been incurred therein. 38 U.S.C.A. §§ 101, 1101, 1110, 1131, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.307, 3.309 (2013). 2. A low back disorder, to include degenerative joint disease of the lumbar spine, was not incurred in or aggravated by active service to include during a period of ACDUTRA or INACDUTRA, nor may it be presumed to have been incurred in service. 38 U.S.C.A. §§ 101, 1101, 1110, 1131, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309 (2013). 3. A knee disorder, to include degenerative joint disease of the knee, was not incurred in or aggravated by active service to include during a period of ACDUTRA or INACDUTRA nor may it be presumed to have been incurred therein. 38 U.S.C.A. §§ 101, 1101, 1110, 1131, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2013). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. As it relates to the claim for service connection for low back and knee disorders, the RO, in a December 2007 letter, provided the Veteran with notice that informed him of the evidence needed to substantiate his claims. The letter also told him what evidence he was responsible for obtaining and what evidence VA would undertake to obtain. The letter further told him to submit relevant evidence in his possession. The December 2007 letter also provided the Veteran with notice as to the disability rating and effective date elements of the claim. As it relates to the claim for service connection for hypertension, the RO, in a February 2011 letter, provided the Veteran with notice that informed him of the evidence needed to substantiate his claim. The letter also told him what evidence he was responsible for obtaining and what evidence VA would undertake to obtain. The letter further told him to submit relevant evidence in his possession. The February 2011 letter also provided the Veteran with notice as to the disability rating and effective date elements of the claim. As it relates to the duty to assist and all issues, the Board finds that there has been substantial compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, VA treatment records, private treatment records, and lay evidence. The Board notes that several attempts were made to obtain additional service treatment records from the Rhode Island National Guard which were unsuccessful. A formal finding of Unavailability of Service Records was made in June 2009. The Veteran was notified of the unavailability in a June 2009 letter and given the opportunity to submit any additional records in his possession. No additional pertinent evidence has been identified by the claimant. As it relates to the claim of service connection for low back and knee disorders and the necessity for a VA examination, the Board notes that in determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). An examination is not warranted under 38 U.S.C.A. § 5103A(d) for low back or knee disorders because there is no competent evidence that the Veteran's currently claimed low back and knee disorders are related to service, and there is other sufficient medical evidence of record to make a decision. Moreover, the Veteran was previously informed in the VCAA letter noted above that he needed to provide medical evidence showing the disorder had existed since service. He has not done so. As such, a VA medical examination is not necessary. As it relates to the issue of service connection for hypertension, the Board notes that the Veteran was afforded a VA examination in July 2012 and an addendum opinion was added in August 2012. The examination report provided a detailed history and sufficient detail with regard to the etiology of the hypertension and its relationship to the Veteran's period of service. Moreover, there is no in-service injury, disease, or event, so there is no need for a VA examination. See Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010) (holding that where the evidence has failed to establish an in-service injury, disease, or event, VA is not obligated to provide a medical examination). The Veteran also appeared at a Board videoconference hearing before the undersigned Veterans Law Judge in June 2013. In Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer (DRO) or Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issue and (2) the duty to suggest the submission of evidence that may have been overlooked. During the June 2013 hearing, the VLJ noted the issues on appeal and took testimony with regard to the Veteran's beliefs as to why the claimed disorders were related to his period of service. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim including asking about symptoms and asking for all possible treatment records and inquiring as to where the Veteran was receiving current treatment. The Board left the record open so that the Veteran could submit evidence in support of his claim. The Veteran has not done so. The hearing focused on the elements necessary to substantiate the claim and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits. In addition, the Veteran was represented by an accredited representative. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and arguments presented by his representative and by his appearing at a videoconference hearing. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. Service Connection-General Criteria When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. 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, supra, 1 Vet. App. at 57. Service connection may be granted for disability or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, is service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) . Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in the line of duty. 38 U.S.C.A. § 101(21),(24); 38 C.F.R. § 3.6(a). Active military, naval, or air service also includes any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled from an injury incurred in the line of duty. Id. Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ACDUTRA or from injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131. Service connection for a disability on the basis of the merits of such claim requires (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). If a veteran served 90 days or more on active duty, service incurrence will be presumed for certain chronic diseases, including hypertension and arthritis, if manifest to a compensable degree within the year after active service. 38 C.F.R. §§ 3.307(a), 3.309(a). The conditions of back and knee disorders, diagnosed as degenerative joint disease of the spine and knees, and hypertension, are "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See 38 U.S.C.A. § 1153(a) (West 2002); 38 C.F.R. § 3.303(a); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), and Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Service Connection for Hypertension on a Direct and Presumptive Basis The Veteran maintains that his current hypertension had its onset during his period of active service while stationed in Greenland. He has reported that he was told that he had hypertension at that time. After a review of all the evidence, the Board finds that there was no cardiovascular disease or injury during service; hypertension did not begin during active service or for many years after service nor did it have its onset during a period of ACDUTRA or INACDUTRA; symptoms of hypertension were not chronic in service; symptoms of hypertension were not continuous since service; hypertension did not manifest to 10 percent within one of service separation; and the current diagnosis of hypertension is not related to service. The Veteran's service treatment records reveal that there were no complaints or findings of hypertension or high blood pressure readings during the Veteran's his period of service and no in-service cardiovascular injury or disease, demonstrating no chronic symptoms in service. The Board does note that the Veteran was found to have a blood pressure reading of 140/80 on his July 1962 service entrance examination; however, there were no further readings of elevated blood pressure in service and at the time of the April 1965 service separation examination, normal findings were reported for the heart and vascular system, with the Veteran's blood pressure reported as 128/68. There are also no complaints or findings of hypertension in the years immediately following service. Treatment records do not reveal any findings of hypertension until decades after service. Therefore, the evidence does not reflect continuity of symptomatology, for reasons clearly noted above, with significant evidence against such a finding. Treatment records which have been associated with the claims folder make no reference to any findings of hypertension until many years following service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving a claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). In this case, the Board finds that the Veteran's reported history of continued symptomatology since active service, while competent, is not credible. As noted above, the Veteran did not report having hypertension in service, with normal blood pressure readings being reported at the time of the Veteran's April 1965 service separation examination. Moreover, the Veteran, on his April 1965 service separation report of medical history, checked the "no" boxes when asked if he had or had ever had high or low blood pressure or palpitation or pounding heart. In addition to there being no findings of hypertension for many decades following service, the Veteran has indicated that he was first diagnosed as having hypertension in 1991. The above evidence is more probative than his recent assertions that his current hypertension had its onset in service, if that is what he is indeed claiming, voiced many years after service and in connection with a claim for disability benefits. For the above reasons, continuity has not here been established, either through the clinical record or through the Veteran's own statements. The Veteran's current hypertension has no nexus to service with no evidence of onset in service or occurrence in service. As to the Veteran's belief that his current hypertension problems are related to his period of service, the question of causation of hypertension to service extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. The Veteran is not competent to diagnose hypertension as such findings are identified by specialized diagnostic testing, such as blood pressure readings. See Jandreau at 1377. Next, service connection may be granted when the evidence establishes a medical nexus between active duty service and current disability. In this case, there is lack of competent medical evidence of record relating any current hypertension to the Veteran's period of service. The Veteran was afforded a VA examination in July 2012. The examiner diagnosed the Veteran as having hypertension. The examiner noted that the Veteran first reported developing hypertension in Greenland. He stated that he was told that he had hypertension at that time but received no further treatment. The examiner noted the elevated reading at the time of the Veteran's service entrance examination. In an August 2012 addendum, the examiner indicated that it was not at least as likely as not that the Veteran's hypertension began in service. When evaluating the weight of medical evidence, the Board is guided by the principle that the probative value of a medical opinion largely rests upon the extent to which such opinion is based upon a thorough evaluation of the Veteran's medical history, including but not limited to the medical evidence contained in the claims file. See, e.g. Miller v. West, 11 Vet. App. 345, 348. The Board may examine the factual foundation of a medical opinion, including whether the physician had access to relevant information of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). The Board finds that the opinion of the July 2012 VA examiner is the most probative. The July 2012 VA examiner reviewed the Veteran's entire claims file, which at the time included his service treatment records, VA treatment records, private treatment records, and statements and testimony from the Veteran. Based on all the evidence, the examiner rendered an opinion that was supported by rationale. There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact. Thus, the Board finds this opinion to be the more probative evidence of record on the question of relationship of currently diagnosed hypertension to service. In sum, the preponderance of the evidence weighs against a finding that any current hypertension is related to the Veteran's period of service or any period of ACDUTRA or INACDUTRA, direct and presumptive (38 C.F.R. §§ 3.303(b), 3.307, 3.309). As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); 3.102. Service Connection for a Low Back Disorder The Veteran asserts that his low back disorder began during his period of active service, initially injuring his back during basic training and then falling on his back on several occasions while stationed at Ft. Thune in Greenland. He indicated that he fell several times during his period of active service as a result of the harsh conditions he encountered while in Greenland. The Veteran has also indicated that he injured his back while falling off a signal fan while performing duties as part of the Rhode Island National Guard during a drill weekend. He has further reported injuring his back during a two week period while at Camp Edwards during two weeks of active duty training with the Rhode Island National Guard. The Veteran does not allege, and a review of his official military documentation contained in his claims file does not otherwise indicate, that he engaged in combat against enemy forces as contemplated by VA regulations. His DD Form 214 does not reflect that he received any decorations or medals indicative of involvement in combat and there is no other evidence of combat. For these reasons, the Board finds that the Veteran did not "engage in combat" with the enemy during his period of active service. After a review of all the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not sustain an injury or disease of the low back during active service or during a period of ACDUTRA or INACDUTRA, that the Veteran did not have chronic symptoms of a low back disorder during his period of active service, that the Veteran did not experience continuous symptoms of a low back disorder after active service, that currently diagnosed lumbar spine arthritis is not related to service, and that lumbar spine arthritis did not manifest to 10 percent within one of service separation. In this case, the service treatment records are negative for any complaints, treatment, or diagnoses related to a low back disorder. See 38 C.F.R. § 3.303(a),(b). The Board also finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of a back disorder. Medical records show that the Veteran's first post-service treatment for low back pain did not occur until many years following service in March 2006, when the Veteran was found to have degenerative joint disease of the lumbar spine. The Veteran did not give a history of any injury or disease of the back during service, or chronic symptoms during service, or continuous symptoms since service separation prior to 2007. He first made such assertions at or after the time that of his current VA claim for compensation in 2007. Although the Veteran is competent to report certain symptoms of a low back disorder, the Board finds that his recent reports of low back symptoms in service and continuous symptoms since active service are inconsistent with, and outweighed by, his own previously reported histories and other evidence of record, and are not credible. As noted above, the Veteran did not assert that he had a diagnosis of a low back disorder until 2007. Although the Veteran now asserts that he had a low back disorder related to his service, he did not allege that his current complaints of low back pain and diagnosis of a low back disorder were related to active service until he filed his claim for benefits in 2007. The Board has also considered the statements of the Veteran indicating that he had a history of low back pain since active service. His statements are not reliable. The clinical evidence of record, demonstrates no relationship between the Veteran's active service and his current low back disorder, either by direct nexus or by a showing of continuous symptoms since service separation. The Board finds that the recent contentions of the Veteran regarding a low back disorder in service are not credible because his reports are inconsistent with the more contemporaneous service treatment record evidence including the Veteran's own lay reports and history, the absence of complaints or treatment after service, and the Veteran's own histories made for treatment purposes prior to filing his 2007 claim for VA compensation. In his claim for VA benefits, the Veteran claimed service connection for a low back disorder related to a fall while at Camp Edwards in 2001. Prior to the 2007 claim for benefits, it is significant that the Veteran did not make any assertions of chronic symptoms in service or continuous symptoms since active service regarding the claimed low back disorder. In fact, the Veteran did not relate his low back disorder to his period of active service even at the time of his initial application, instead relating it to a 2001 episode. Statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care. See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the appellant's statements, it may consider whether self-interest may be a factor in making such statements); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Such evidence, or lack thereof, weighs against findings of chronic symptoms of a low back disorder in service or continuous symptoms since service. For these reasons, the Board finds that the Veteran's statements that he had chronic symptoms during active service and that he experienced continuous symptoms since service are outweighed by the other, more contemporaneous lay and medical evidence of record, and are not credible. See Caluza at 511; Cromer v. Nicholson, 19 Vet. App. 215, 217 (2005). Therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) are not met. While the record reflects that the Veteran was diagnosed with degenerative joint disease of the low back many years following his period of active service, to substantiate a claim of presumptive service connection for such disability as a chronic disease under 38 C.F.R. §§ 3.307/3.309, there must be evidence that it was manifested to a compensable degree in the first post-service year. A thorough review of the record reflects no degenerative joint disease of the low back in the first post-service year. Although the Veteran has alleged experiencing symptoms during the first post-service year, notably, as a layperson, he is not competent to diagnose degenerative joint disease of the lumbar spine as that disability is an insidious process identified by specialized diagnostic testing, such as x-rays. See Jandreau at 1377. Moreover, as indicated above, such assertions of symptoms in service and continuously after service are not credible. Given that there is no credible evidence of symptoms of degenerative joint disease of the lumbar spine within the first post-service year, service connection for a lumbar spine disorder on a presumptive basis is also not warranted. For these reasons, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran's low back disorder is directly related to his period of service; is against a finding of "chronic" or "continuous" symptom to meet the presumption under 3.303(b); or that arthritis manifested to a degree of at least 10 percent within one year to meet the presumptive provisions under §§ 3.307, 3.309; therefore, the claim for direct service connection and for presumptive service connection of this disability must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. As to the Veteran's contention that his current low back disorder arises out of an injury sustained during a period of ACDUTRA/INACDUTRA, the evidence of record does not contain any such finding. There are various dates of first diagnosis of a low back disorder, to include degenerative joint disease of the lumbar spine, none, except the Veteran's assertions, that mention ACDUTRA or INACDUTRA and none that are specific as to the exact day or month of the injury or diagnosis. With this and the Veteran's vague assertions that the injury was during ACDUTRA as demonstrated by his reported having injured his back in different ways, with no specific dates being reported by the Veteran, and no reflection of injury or symptoms of a low back disorder during ACDUTRA or INACDUTRA, the Board finds that a low back disorder in fact was not diagnosed during a period of INACDUTRA or ACDUTRA, showing no injury in service and no incurrence in service. As such, without evidence that the Veteran's low back disorder arose during a period of ACDUTRA or INACDUTRA, the claim for service connection for a low back disorder must also be denied on this basis. Service Connection for a Bilateral Knee Disorder The Veteran asserts that his bilateral knee disorder began during his period of active service, falling on his knees on several occasions while stationed at Ft. Thune in Greenland. He indicated that that he fell several times during his period of active service as a result of the harsh conditions he encountered while in Greenland. After a review of all the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not sustain an injury or disease of the knees during service or during a period of ACDUTRA or INACDUTRA, that the Veteran did not have chronic symptoms of a knee disorder during his period of active service, that the Veteran did not experience continuous symptoms of a bilateral knee disorder after active service, that currently diagnosed degenerative joint disease of the knees is not related to service, and that degenerative joint disease of the knees did not manifest to 10 percent within one of service separation. In this case, the service treatment records are negative for any complaints, treatment, or diagnoses related to a knee disorder. See 38 C.F.R. § 3.303(a),(b). The Board also finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of a knee disorder. Medical records show that the Veteran's first post-service treatment for a knee disorder did not occur until many years following service, when the Veteran was found to have degenerative joint disease of the knees. The Veteran did not give a history of any injury or disease of the knees during service, or chronic symptoms during service, or continuous symptoms since service separation. He first made such assertions at or after the time that he filed his current VA claim for compensation in 2007. Although the Veteran is competent to report certain symptoms of a knee disorder, the Board finds that his reports of symptoms in service and continuous symptoms since active service are inconsistent with, and outweighed by, his own more contemporaneous previously reported histories and other evidence of record, and are not credible. As noted above, the Veteran did not assert that he had a knee injury or diagnosis of a knee disorder until 2007. Although the Veteran has asserted that he had a knee disorder related to his service, he did not allege that his current complaints of knee disorder and diagnosis of a knee disorder were related to active service until he filed his claim for benefits in 2007. The Board considers the statements of the Veteran indicating that he had a history of knee pain since active service not credible. The clinical evidence of record, does not demonstrate a relationship between the Veteran's active service and his current knee disorder, either by direct nexus or by a showing of continuous symptoms since service separation. The Board finds that the recent contentions of the Veteran regarding a knee injury/symptoms in service are not credible because his reports are inconsistent with the more contemporaneous service treatment record evidence including the Veteran's own lay reports and history, the absence of complaints or treatment after service, and the Veteran's own histories made for treatment purposes prior to filing his 2007 claim for VA compensation that reflect no history of in-service injury or complaints of symptoms or post-service symptoms until 2007. Prior to the 2007 claim for benefits, it is significant that the Veteran did not make any assertions of chronic symptoms in service or continuous symptoms since active service regarding the claimed knee disorder. Statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care. Such evidence, or lack thereof, weighs against findings of chronic symptoms of a knee disorder in service or continuous symptoms since service. For these reasons, the Board finds that the Veteran's statements that he had chronic symptoms during active service and that he experienced continuous symptoms since service are outweighed by the other, more contemporaneous lay and medical evidence of record, and are not credible. Therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) are not met. While the record reflects that the Veteran was diagnosed with degenerative joint disease of the knees many years following his period of active service, to substantiate a claim of presumptive service connection for such disability as a chronic disease under 38 C.F.R. §§ 3.307/3.309, there must be evidence that it was manifested to a compensable degree in the first post-service year. A thorough review of the record reflects no degenerative joint disease of the knees in the first post-service year. Although the Veteran has alleged experiencing symptoms during the first post-service year, notably, as a layperson, he is not competent to diagnose degenerative joint disease of the knees as that disability is an insidious process identified by specialized diagnostic testing, such as x-rays. See Jandreau at 1377. Moreover, as indicated above, such assertions of symptoms in service and continuously after service are not credible. Given that there is a lack of credible evidence of symptoms of degenerative joint disease of the knees within the first post-service year, service connection for a knee disorder on a presumptive basis is also not warranted. For these reasons, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran's knee disorder is directly related to his period of service; is against a finding of "chronic" or "continuous" symptoms to meet the presumption under 3.303(b); or that arthritis manifested to a degree of at least 10 percent within one year to meet the presumptive provisions under §§ 3.307, 3.309; therefore, the claim for direct service connection and for presumptive service connection of this disability must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Assuming arguendo, that the Veteran's claim is that his current knee disorders arise out of injury sustained during a period of ACDUTRA/INACDUTRA, the evidence of record does not contain any such finding. There are various dates of first diagnosis of a knee disorder, to include degenerative joint disease of the knees, none, except the Veteran's assertions, that mention ACDUTRA or INACDUTRA and none that are specific as to the exact day or month of the injury or diagnosis. With this and the Veteran's vague assertions that the injury and/or diagnosis was during ACDUTRA, with no specific dates being reported by the Veteran, and no reflection of injury or diagnosis during ACDUTRA or INACDUTRA, the Board finds that there was no knee injury during a period of INACDUTRA or ACDUTRA. As such, without evidence that the Veteran's current knee disorder arose during a period of ACDUTRA or INACDUTRA, the claim for service connection for a knee disorder must also be denied on this basis. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for hypertension on a direct and presumptive basis is denied. Service connection for a low back disorder is denied. Service connection for a bilateral knee disorder is denied. REMAND Secondary Service Connection for Hypertension As it relates to the Veteran's theory of service connection for hypertension as secondary to his service-connected anxiety disorder, the Board notes that the theory of secondary service connection for hypertension was raised late in the claim. Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2013); Allen v. Brown, 7 Vet. App. 439, at 448 (1995) (holding that service connection on a secondary basis requires evidence sufficient to show that the current disability was caused or aggravated by a service-connected disability). To establish secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). To date, because only recently raised, the Veteran's theory for service connection for hypertension on a secondary basis has not been addressed nor has the Veteran been provided with the regulations regarding secondary service connection. The Veteran has also not been afforded a VA examination to assist in determining whether his current hypertension is caused or aggravated by his service-connected anxiety disorder. VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability; the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). To date, the Veteran has not been afforded a VA examination to address the whether his current hypertension is caused or aggravated by his service-connected anxiety disorder. Based upon the above, the Veteran should be afforded a VA examination with an accompanying opinion. Service Connection for Left Wrist Disorder As it relates to the claim of service connection for a left wrist disorder, the Board notes that the Veteran has claimed that his current left wrist disorder arises as a result of falling and injuring his wrist during his period of active service due to duties performed in harsh weather conditions while at Ft. Thune in Greenland, or, in the alternative, arises from exposure to the cold temperatures while in Greenland, resulting in frostbite causing his carpal tunnel syndrome. The Board notes that the Veteran's private physician, R. C., M.D., in a July 2012 statement, indicated that the he had treated the Veteran for osteoarthritis. The Board further observes that the Veteran has been diagnosed as having bilateral carpal tunnel syndrome. To date, the Veteran has not been afforded a VA examination to address the whether his current left wrist disorder is related to his period of service, to include as a result of cold injury residuals related to his period of service or is due to his bilateral carpal tunnel syndrome. Based upon the above, the Veteran should be afforded a VA examination with an accompanying opinion. Accordingly, the issues of secondary service connection for hypertension and service connection for a left hand disorder are REMANDED for the following action: 1. A VCAA letter should be sent to the Veteran on the issue of entitlement to service connection for a hypertension as secondary to service-connected anxiety disorder. This letter should inform the Veteran of the information and evidence necessary to substantiate the claim in terms of 38 C.F.R. § 3.310 and provide notification of both the type of evidence that VA will seek to obtain and the type of evidence that is expected to be furnished by the Veteran. 2. Schedule the Veteran for the appropriate VA examination to assist in determining the nature and etiology of any current hypertension. The relevant documentation in the claims folder and all other pertinent records should be made available to the examiner. All necessary tests should be performed. The examiner is requested to offer the following opinions: a. Is it as likely as not (50 percent probability or greater) that any current hypertension is caused by the service-connected anxiety disorder? b. If not, is it at least as likely as not (50 percent probability or greater) that any current hypertension is aggravated (permanently worsened) by the service-connected anxiety disorder? Complete detailed rationale is requested for each opinion that is rendered. 3. Schedule the Veteran for the appropriate VA examination to assist in determining the nature and etiology of any current left hand disorder. The relevant documentation in the claims folder and all other pertinent records should be made available to the examiner. All necessary tests should be performed. The examiner is requested to offer the following opinion: Is it as likely as not (50 percent probability or greater) that any current left hand disorder, to include carpal tunnel syndrome, is related to the Veteran's period of service, to include as a result of cold exposure while in Greenland? Complete detailed rationale is requested for each opinion that is rendered. 4. Following the completion of the above to the extent possible, the RO should readjudicate the remaining claims on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case, and should be given the opportunity to respond thereto before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the 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). ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs