Citation Nr: 1335507 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 09-13 334 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for a left hand disability claimed as left hand arthritis secondary to service-connected diabetes mellitus, type II. 2. Entitlement to service connection for a right hand disability, claimed as right hand arthritis secondary to service-connected diabetes mellitus, type II. 3. Entitlement to service connection for a left wrist disability, claimed as left wrist arthritis secondary to service-connected diabetes mellitus, type II. 4. Entitlement to service connection for a right wrist disability, claimed as right wrist arthritis secondary to service-connected diabetes mellitus, type II. 5. Entitlement to service connection for a left arm disability, claimed as left arm arthritis secondary to service-connected diabetes mellitus, type II. 6. Entitlement to service connection for a right arm disability, claimed as right arm arthritis secondary to service-connected diabetes mellitus, type II. 7. Entitlement to service connection for a left shoulder disability, claimed as left shoulder arthritis secondary to service-connected diabetes mellitus, type II. 8. Entitlement to service connection for a right shoulder disability, claimed as right shoulder arthritis secondary to service-connected diabetes mellitus, type II. 9. Entitlement to service connection for a cervical spine disability, claimed as cervical spine arthritis secondary to service-connected diabetes mellitus, type II. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD T. Adams, Counsel INTRODUCTION The Veteran had service from April 1971 to April 1973. These matters are on appeal from a September 2006 decision by the Department of Veterans Affairs (VA), Regional Office (RO) in New Orleans, Louisiana. The Veteran requested a Travel Board hearing before a Veterans Law Judge in his March 2009 substantive appeal, but withdrew his request for a hearing in May 2010. The matter was most recently Remanded in February 2011 for additional development. Additional evidence was included in the record after the agency of original jurisdiction (AOJ) last considered the issues on appeal in May 2012. However, in a statement dated in October 2013, the Veteran, through his representative, waived AOJ consideration of that evidence. FINDINGS OF FACT 1. Left and right hand disabilities, diagnosed as degenerative joint disease (DJD) and moderately severe carpal tunnel syndrome, were not documented in service or within one year thereafter; and, the preponderance of the evidence fails to establish that these disorders were caused or aggravated by the Veteran's active service or service connected diabetes mellitus, to include the medications used to treat it. 2. Left and right wrist disabilities, diagnosed as DJD, were not documented in service or within one year thereafter; and, the preponderance of the evidence fails to establish that these disorders were caused or aggravated by his active service or service connected diabetes mellitus, to include the medications used to treat it. 3. Left and right arm disabilities, diagnosed as DJD of the elbows, were not documented in service or within one year thereafter; and, the preponderance of the evidence fails to establish that these disorders were caused or aggravated by his active service or service connected diabetes mellitus, to include the medications used to treat it. 4. Left and right shoulder disabilities, diagnosed as DJD and tendinitis of the left shoulder and DJD of the AC joint of the right shoulder, were not documented in service or within one year thereafter; and, the preponderance of the evidence fails to establish that these disorders were caused or aggravated by his active service or service connected diabetes mellitus, to include the medications used to treat it. 5. A cervical spine disability, diagnosed as cervical spondylosis C5-C6, was not documented in service or within one year thereafter; and, the preponderance of the evidence fails to establish that the Veteran's cervical spondylosis C5-C6 was caused or aggravated by his active service or service connected diabetes mellitus, to include the medications used to treat it. CONCLUSIONS OF LAW 1. The criteria for service connection for left and right hand disabilities have not been met. 38 U.S.C.A. §§ 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2013). 2. The criteria for service connection for left and right wrist disabilities have not been met. 38 U.S.C.A. §§ 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2013). 3. The criteria for service connection for left and right arm disabilities have not been met. 38 U.S.C.A. §§ 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2013). 4. The criteria for service connection for left and right shoulder disabilities have not been met. 38 U.S.C.A. §§ 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2013). 5. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C.A. §§ 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via a letter dated in June 2006 of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified via a letter dated in December 2007 of the criteria for establishing secondary service connection and how VA determines disability ratings and effective dates if service connection is awarded. Nothing more was required. Although the Veteran was not provided complete notice until after the initial adjudication of the claims, the Board finds that there is no prejudice to him in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the Veteran's claims. See March 2009 Statement of the Case and May 2012 Supplemental Statement of the Case. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claims would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). Regarding VA's statutory duty to assist in claims development, the record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the bilateral hand, arm, shoulder and cervical spine claims. Pertinent medical evidence associated with the claims files consists of service and VA treatment records and the reports of September 1987, February 1990, and November 2001 VA examinations. In addition, pursuant to the Board's July 2011 Remand the Veteran was afforded VA hand, thumb, fingers and joints examinations in July 2011. Consideration has been given to the Veteran's argument, though his representative, that "this case may need an outside medical opinion by a specialist to properly adjudicate these issues." The Board does not agree. 38 C.F.R. § 20.901(d) provides that the Board may solicit an advisory medical opinion if it is determined that such an opinion is warranted "by the medical complexity or controversy involved in an appeal." Here, the July 2011 opinions are more than adequate in addressing the medical questions raised in this appeal. There is no unresolved medical question. The report of examination shows that all subjective and objective findings necessary for evaluation of the Veteran's bilateral arm, hand, wrist, shoulder, and cervical spine claims were observed and recorded. The examiner took into account the Veteran's lay history and complaints, to include his assertion his use of Avandia for his diabetes mellitus had caused or aggravated his arthritis. The opinions considered all of the pertinent evidence of record, to include the relevant service treatment and post-service treatment records of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. The opinions were also responsive to the questions posited by the Board. The Board further finds that VA substantially complied with the Board's remand directives in further developing the Veteran's claims. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). Indeed, the medical evidence has been thoroughly developed in this case. The competent and credible evidence includes a July 2011 VA examination and opinions that which fail to support a finding that any currently diagnosed bilateral arm, hand, wrist, shoulder and cervical spine disabilities are etiologically related to the Veteran's period of active military service or to his service-connected diabetes mellitus, Type II. Thus, no additional medical examinations or opinions are necessary under the circumstances of this case. Also of record and considered in connection with the appeal are various statements submitted by the Veteran and his representative, on his behalf. Neither the Veteran nor his representative throughout the course of this appeal has made the RO or the Board aware of any other evidence relevant to his appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims adjudicated herein. Therefore, in view of the foregoing, the Board will proceed with appellate review. II. Legal Principles It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). The Board has thoroughly reviewed all the evidence in the record. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence of record shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). 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. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court of Appeals for Veterans Claims held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. 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. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). In general, service connection requires competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, such as arthritis and organic diseases of the nervous system, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a); arthritis and/or degenerative disc disease is a qualifying chronic disease. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As a result, service connection via the demonstration of continuity of symptomatology is applicable in the present case. Service connection may 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) (2013). Service connection may also be granted when a claimed disability is found to be proximately due to or the result of a service-connected disability, or when any increase in severity (aggravation) of a nonservice-connected disease or injury is found to be proximately due to or the result of a service-connected disability, not to the natural progress of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(a) (2013); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence, generally medical, establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Lay persons can also provide an eye-witness account of an individual's visible symptoms. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted into the record. See 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"). The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1137 (Fed. Cir. 2006). Factors for consideration in assessing credibility include a showing of interest, bias, inconsistent statements, consistency with other evidence, and a lack of contemporaneous medical evidence, although that alone may not bar a claim for service connection. Buchanan, 451 F.3d at 1336-37; Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996), superseded in irrelevant part by statute, Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000). 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). III. Background At the outset the Board notes that the Veteran is service connected for diabetes mellitus. He is also in receipt of compensation for peripheral neuropathy of the upper and lower extremities, which were found to be related to his diabetes mellitus. Thus, the scope of the claim for service connection for disabilities of the upper extremities (hands, wrists, arms, and shoulder) is limited to his orthopedic problems such as arthritis and any neurological disorder other than peripheral neuropathy. The STRs are void of any treatment or diagnosis of any left and right hand, left and right wrist, left and right arm, left and right shoulder, or cervical spine disabilities. The Veteran does not contend otherwise. See July 2011 VA examination. There is also no evidence that arthritis or any neurological disorder had its onset within one year of his service discharge. Rather, the Veteran argues that he developed disabilities of the left and right hand, left and right wrist, left and right arm, left and right shoulder, and cervical spine as a result of his service-connected diabetes mellitus, type II. Specifically, he argues that he developed a chronic disability in each of these body parts, to include arthritis; due to the medication he is prescribed to control his diabetes. Post service, the Veteran was afforded a VA general medical examination in September 1987 which indicated a normal musculoskeletal examination. VA treatment records include a July 1989 report which indicates that the Veteran was involved in a motor vehicle accident (MVA) during which he sustained a flexion extension injury of his neck, pain in the left shoulder, and some numbness in the left arm. He also experienced localized numbness in the dorsum of the back of the hand of the left side adjacent to the origin of the left middle finger and the origin of the left thumb. A cervical spine X-ray examination was normal. The diagnoses included improving C-6 radiculopathy, left side, rule out bilateral ulnar neuropathy. VA treatment records dated from September 1990 to October 1990 show that the Veteran reported that he was in a MVA in 1989 during which he sustained injury to his left arm and head. A complaint of numbness in his hands was noted. In September 1990, he had residual stiffness in his neck due to the MVA. A May 1990 social work report also references the MVA and the Veteran's complaint of a pinched nerve in the left hand and a loss of feeling in the left index finger. In March 1993, an examination indicated decreased strength and grip in the left hand secondary to a MVA in the 1980s according to the Veteran. A November 1996 report which indicates that the Veteran had a pinched nerve in the left hand secondary to a MVA and a sensory change in the left hand. Examination of the left hand indicated a limited range of motion secondary to trauma from the MVA when he was thrown from a car. Diagnoses included non-insulin dependent diabetes mellitus, poor control and left hand nerve impairment. A June 1996 report indicates a complaint of a stiff neck related to pain and a history of a neck injury. On April 2001 musculoskeletal examination of the left arm the Veteran complained of generalized joint pain and stiffness and muscle weakness in the left arm after a MVA in 1989. A June 2001 report which indicates a diagnosis of degenerative joint disease (DJD), generalized, involving the left hand. In November 2001, X-ray examinations of the Veteran's hands and wrists were normal. Gouty arthritis was noted/diagnosed when the Veteran underwent a VA diabetes mellitus examination in November 2001. In May 2003, the Veteran complained of a swollen wrist. A January 2005 X-ray examination revealed a little olecranon spur in the left forearm, with no evidence of bursitis and a January 2005 report indicates a diagnosis of DJD of the left shoulder. A January 2005 X-ray examination of the left shoulder indicated some limitation of rotation. An October 2005 MRI right shoulder indicated mild acromioclavicular (AC) arthropathy, tendinopathy or partial thickness tear of the anterior portion supraspinatus tendon. A March 2006 X-ray examination of the right shoulder revealed that the right shoulder joint was intact, but the AC joint was relatively narrowed, resulting in a diagnosis of mild AC joint osteoarthritis of the right shoulder. A March 2006 report indicates a complaint of bilateral shoulder pain that ran down the right arm into the hand. It was noted that an X-ray of the right shoulder indicated mild AC joint osteoarthritis and minimal spondylotic changes of the lower cervical spine, but no indication of significant neural foraminal narrowing. The assessment was some limitation of functional use of the right shoulder secondary to pain from probable C-spine pathology and possible very mild impingement. A June 2006 report indicates a complaint of right shoulder and neck pain. A June 2006 X-ray examination revealed minimal spondylitic changes at the lower cervical spine. A December 2006 report indicates that an examination of the right shoulder revealed impingement versus a partial tear with AC arthropathy and possible neurocompression in the cervical spine. A June 2007 X-ray examination indicated right shoulder impingement symptoms-significant improvement and cervical myelopathy. The assessment was right sided cervical HNP, C 5/6, rule out radiculopathy. A June 2007 EMG indicated moderately severe bilateral CTS, worse on the right. An April 2008 report indicated a history of arthritis. In April 2008, the Veteran complained of left arm pain and the assessment was herpes zoster. A May 2008 report indicated that the Veteran suffered from general arthritis pain. The Veteran was afforded a VA hand, thumb, fingers and joints examination in July 2011. With regard to his cervical spine, the Veteran reported an onset of the disability in 2001. He complained of hurting and cramping in his neck with radiation of pain down to his right shoulder with tingling in his right arm and hand. He also complained of stiffness in his neck. He denied any MVA or specific injury that he could recall. On examination, the examiner diagnosed cervical spondylosis with radiculopathy C5-C6 the onset of which appeared to be consistent with the 1990 diagnosis. The examiner opined that the Veteran's cervical spine disability was not caused or aggravated by any medications used to treat the Veteran's service-connected disabilities including diabetes or to any incident of active duty service. Reference was made to the Veteran's post-service MVA that had caused a flexion/extension injury of his neck resulting in pain to the left shoulder with some numbness in the left arm. The examiner later noted that there was no evidence that any medication the Veteran had taken, and in particular Avandia, caused his arthritis or any other allergic response. With regard to his hands and wrists, the Veteran reported a history of pain in his wrists since 2001. However, the examiner noted that a diagnosis of suspected ulnar neuropathy was rendered as early as 1990, and that a diagnosis of bilateral median sensory motor neuropathy in the region of the wrist consistent with CTS was made in May 2002. On examination, the examiner diagnosed DJD of the right and left hands and bilateral moderately severe CTS and degenerative joint disease of the left and right wrist by X-ray examination in 2011. The examiner opined that these disabilities were not at least as likely as not caused by or aggravated by any medications that the Veteran currently takes nor were they caused by Avandia which the Veteran has named. The examiner further opined that it is not at least as likely as not that these diagnoses were related to any incident of the Veteran's active duty service. The examiner explained that DJD of the Veteran's right hand and CTS along with DJD of the right wrist have a remote onset from the Veteran's active duty service. The CTS was diagnosed in 2002 and the examiner stated that the Veteran was not diagnosed with any hand DJD until 2011. The Board observes that the record instead reflects a 2001 diagnosis of DJD of the left hand rather than in 2011. This oversight by the examiner does not, in any way, lessen the probative value of the opinion that the Veteran's bilateral hand disability is not directly related to his service since the Veteran has categorically denied any problems with his hands during service. Rather, his main contention is that any bilateral hand disability is related to medication prescribed to treat his service-connected diabetes mellitus, a contention which is wholly unsupported by the evidence of record. With regard to the Veteran's arms and shoulders, the Veteran stated that his complaints of pain in his arms and shoulders began in 2001. There was no evidence of any impairment of the left or right arm on examination. However, the examiner diagnosed DJD of the left and right elbow per X-ray examination in July 2011 and DJD and tendinitis of the left shoulder, and DJD of the AC joint of the right shoulder. The examiner opined that the Veteran's DJD of the right and left elbow is not at least as likely as not caused by or aggravated by any medications that the Veteran used to treat his service-connected disabilities including the use of Avandia in the past. Again, while the Veteran attributed his Avandia to arthritis based on media reports that Avandia adversely affected diabetics, there is no documentation in his medical records that Avandia has caused any adverse effect upon the Veteran and it is not listed as an allergy in his medical records. The examiner further opined that it was not at least as likely the Veteran's disabilities began in service. The rationale was that DJD of the left and right elbow was not made until 2011, that the Veteran had no elbow complaints during service, and that the "problem list" as noted in the VA treatment records did not indicate a diagnosis of DJD. In addition, intermittent VA examinations did not indicate DJD of the elbows and his arms were normal in examination. The Board finds that the claims must be denied. The Veteran was not shown to have disabilities of the left or right hand, left or right wrist, left or right arm, left or right shoulder, or any cervical spine disability during service or even within one year of his discharge from service. The earliest post-service medical evidence of any relevant findings of arthritis of the left hand was in 2001, the right hand in 2011, the left shoulder in 2005, the right shoulder in 2006, the wrists and elbows in 2011, and the cervical spine in 1990. In this regard, the only competent opinion of record is the July 2011 VA opinion stating the following: that it is not likely that the Veteran's cervical spondylosis with radiculopathy C5-C6; DJD and CTS of the hands; DJD of the wrists and elbows; and DJD and tendinitis of the left shoulder and DJD of the AC joint of the right shoulder were caused by or aggravated by any medications that the Veteran used to treat his service-connected disabilities, including the use of Avandia in the past and that it is not at least as likely as not that these disabilities began in service. Rationale was provided with these opinions. There is also no conflicting medical opinion. There is likewise no persuasive evidence that the Veteran has been experiencing chronic symptoms related to these diagnoses since service. He really makes no such contention. In this regard, the VA examiner suggested that the Veteran's left shoulder and left arm complaints were related to a post-service MVA and subsequent neck injury. Service connection based on the theories of direct onset (38 C.F.R. § 3.303(a)), a presumption of service connection (38 C.F.R. § 3.307, 3.309), continuity of symptomatology (38 C.F.R. § 3.303(b)), or on a secondary basis (38 C.F.R. § 3.310) is not established. Consideration has been given to the Veteran's assertion that his arthritis and disabilities of the upper extremities (other than peripheral neuropathy) are the result of medications (Avandia) that are used to treat his service connected diabetes mellitus. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, an opinion as to the etiology and onset of arthritis (DJD), carpal tunnel syndrome, tendinitis, and cervical spondylosis with radiculopathy and whether these diseases are etiologically related to the Veteran's active service or to his service-connected diabetes mellitus or medications used to treat that condition, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Arthritis, carpal tunnel syndrome, tendinitis, and cervical spondylosis with radiculopathy are not the type of conditions that are readily amenable to mere lay diagnosis or probative comment regarding their etiology, as the evidence shows X-ray studies and other specific findings are needed to properly assess and diagnose the disorders. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that Veteran is competent to report symptoms such as pain, numbness, and stiffness, there is no indication that the Veteran is competent to etiologically link any such symptoms to his active service or to his service-connected diabetes mellitus. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. His assertion of there being a correlation between the medications prescribed for treatment of his diabetes and his development of disabilities of the arms, hands, wrists, shoulders, and cervical spine is beyond his competency as well. Nothing in the record demonstrates that he has received any special training or acquired any medical expertise in evaluating orthopedic or neurological disorder. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). He also not produced anything more than anecdotal references to there being a possibility that the use of Avandia could cause arthritis. Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. For these reasons, the Board finds that the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for left and right hand, left and right wrist, left and right arm, left and right shoulder, and cervical spine disabilities on either a direct, presumptive, or secondary basis. In reaching this conclusion, the Board notes that under the provisions of 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102, a reasonable doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a left hand disability claimed as left hand arthritis secondary to service-connected diabetes mellitus, type II, is denied. Service connection for a right hand disability, claimed as left hand arthritis secondary to service-connected diabetes mellitus, type II, is denied. Service connection for a left wrist disability, claimed as left wrist arthritis secondary to service-connected diabetes mellitus, type II, is denied. Service connection for a right wrist disability, claimed as left wrist arthritis secondary to service-connected diabetes mellitus, type II, is denied. Service connection for a left arm disability, claimed as left arm arthritis secondary to service-connected diabetes mellitus, type II, is denied. Service connection for a right arm disability, claimed as left arm arthritis secondary to service-connected diabetes mellitus, type II, is denied. Service connection for a left shoulder disability, claimed as left shoulder arthritis secondary to service-connected diabetes mellitus, type II, is denied. Service connection for a right shoulder disability, claimed as left shoulder arthritis secondary to service-connected diabetes mellitus, type II, is denied. Service connection for a cervical spine disability, claimed as cervical spine arthritis secondary to service-connected diabetes mellitus, type II, is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs