Citation Nr: 1342591 Decision Date: 12/23/13 Archive Date: 12/31/13 DOCKET NO. 12-33 498 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety and depression. 2. Entitlement to service connection for a low back condition. REPRESENTATION Appellant represented by: Tonya Scott, Agent ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran had active service from July 1969 to October 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. The case was remanded for further development in August 2013, and has been returned to the Board. The Board has reviewed the contents of the Veteran's Virtual VA file and found that it contains additional medical evidence which is not included in the paper claims file. VA treatment records dated from December 2000 to September 2012 were uploaded into the e-folder in October 2012 and were specifically listed among the evidence considered in the October 2012 statement of the case (SOC). VA treatment records dated in October and November 2012 were uploaded into the e-folder in December 2012 and VA treatment records dated from January to September 2013 were uploaded into the e-folder in September 2013. Although the VA treatment records uploaded in December 2012 and September 2013 were not specifically referenced in the October 2013 supplemental SOC (SSOC), they were associated with the Veteran's record (his Virtual VA e-folder) at that time. The Board presumes that the RO considered all evidence of record in preparation of the October 2013 SSOC. See Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000) ("absent specific evidence indicating otherwise, all evidence contained in the record at the time of the RO's determination of the service connection must be presumed to have been reviewed by the Department of Veterans Affairs, and no further proof of such review is needed."). Further, while the evidence associated with the e-folder in December 2012 includes a November 2012 opinion that the Veteran's low back condition could not be attributed to a specific traumatic event, this is essentially the same opinion which was provided by another VA provider in May 2012. This May 2012 record was specifically considered in the October 2013 SSOC. Therefore, the Board's consideration of the evidence uploaded into the e-folder after issuance of the October 2012 SOC will not result in prejudice to the Veteran. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran sustained PTSD as a result of active military service. 2. A low back condition was not incurred in or aggravated by service and degenerative changes in the lumbar spine were not manifest within one year of separation from service. CONCLUSIONS OF LAW 1. The criteria for the establishment of service connection for PTSD are met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304(f) (2013). 2. The criteria for the establishment of service connection for a low back condition are not met or approximated. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. Duty to Notify and Assist Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2013). The VCAA notice requirements apply to all elements of a claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Given the favorable disposition of the claim for service connection for a psychiatric disorder, the Board finds that all notification and development actions needed to fairly adjudicate this claim have been accomplished. Regarding the claim for service connection for a low back condition, the Veteran was provided with the relevant notice and information in an April 2011 letter prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). VA also has a duty to assist the Veteran in obtaining potentially relevant records, and providing an examination or medical opinion when necessary to make a decision on the claim. Here, the Veteran's service records, VA treatment records, Social Security Administration (SSA) records, and private treatment records have been obtained and associated with the claims file. The Veteran has not been afforded a VA examination to assess the nature and etiology of his claimed low back condition. VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, however, there is no competent evidence of record to support a finding that the Veteran's claimed low back condition is related to service. The Veteran has alleged that this condition is related to service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), determining the etiology and diagnosis of a low back 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); see also Waters v. Shinseki, 601 F.3d 1274, 1279 (Fed. Cir. 2010) (the Veteran's conclusory lay statement is insufficient to trigger VA's duty to provide an examination with an opinion). The McLendon elements have not been satisfied and VA is not required to provide the Veteran with a VA examination in conjunction with his claimed low back condition. In August 2013, the Board remanded the claim for service connection for a lumbar spine disability to obtain private treatment records from several physicians, specifically, Dr. B.P., Dr. M., Dr. K., Dr. A.K., Dr. R., and Dr. S., as well as Atlantic Spine. Later that month, the Veteran responded that records from Dr. B.P., Dr. M., and Dr. K. had previously been submitted in conjunction with a 2000 claim for pension benefits. He reported that these records were no longer available. He added that records from Dr. A.K., Dr. R., and Dr. S. were included in his SSA records. Nevertheless, the Veteran was advised via letter and telephone to submit VA Form 21-4142s, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), for his private treatment records. The Veteran submitted another statement in August 2013 in which he reported that the records from Dr. B.P., Dr. M., Dr. K., Dr. A.K., Dr. R., and Dr. S. no longer exited. He added that he had never been seen at Atlanta Spinal Care, but only had a phone discussion regarding his MRI and X-rays. A September 2013 Report of Contact reflects that the Veteran would not be sending in any VA Form 21-4142 for any private treatment records; however, he subsequently provided releases for records from Dr. A.C. (previously identified as Dr. A.K.) at Albany Medical Center, Dr. R., and Dr. S; however, he did not provide complete addresses for these physicians. While he provided a release for records from Dr. M., he stated that this physician treated him for a right side hernia and not for a service-connected disability. In his release for Atlanta Spinal Care, he reported that he only had phone contact with this provider and was never seen in person or treated. The Veteran returned a release for records from Dr. B.P. and Dr. K. (each regarding treatment for psychiatric conditions). Records were requested from Dr. B.P. and Dr. K., but negative responses were received. The October 2013 SSOC advised the Veteran of the above development regarding these private treatment records, and he submitted an SSOC notice response later that month indicating that he had no other information or evidence to submit. VA is only obligated to obtain records that are adequately identified and for which necessary releases have been received. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran did not provide releases including complete addresses for Dr. A.C., Dr. R., and Dr. S.; however, treatment records from Albany Medical Center are included in the Veteran's SSA records. In any event, the Veteran has reported that the records requested in the August 2013 remand are not available. In light of the above, further attempts to obtain additional private treatment records are not warranted. There was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). An April 1998 Workers' Compensation Board record reflects hat the Veteran was diagnosed with thoracolumbar strain. Complete workers' compensation records regarding this injury have not been requested; however, physical therapy records regarding the Veteran's March 1998 work injury are of record. In January 2012, the Veteran reported receiving emergency room treatment for his back shortly after separation from service. Actual emergency room records regarding treatment for a back condition shortly after separation from service have not been associated with the claims file. The Veteran reported in March 2011 that he had a fire in April 2010 in which he lost medical records, including X-rays and emergency room records regarding his back. In the April 2011 VCAA letter, the RO asked the Veteran to complete and return a VA Form 21-4142 for each health care provider so VA could obtain treatment information. The Veteran has not identified or provided a necessary release to allow VA to obtain additional workers' compensation records or records of emergency room treatment dated shortly after service. Therefore, no additional development regarding such records is necessary. The Veteran has not identified any additional, relevant evidence that has not been requested or obtained. The Veteran has been notified of the evidence and information necessary to substantiate his claim, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claim. Analysis - Psychiatric Disorder The Veteran has three months and three days of active military duty. He was separated from the service due to a finding of "unsuitability" by a military board. He alleges that he has PTSD as a result of events which occurred during his U.S. Marine Corps recruit training. In substance, he alleges that during his assignment to a "motivational" platoon, he was assaulted by a drill instructor who forced the Veteran's head underwater and who threw ammunition cans at him. The Veteran has been diagnosed in part with PTSD by both his treating physician in August 2013 and by a separate VA examiner in September 2013. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. Generally, in order to prevail on the merits on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances lay, evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Generally, service connection for PTSD requires medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an inservice stressor; and credible supporting evidence that the claimed inservice stressor occurred. 38 C.F.R. § 3.304(f). However, when a claimant seeks service connection for PTSD, based on in-service personal assault, evidence from sources other than the Veteran's service records may corroborate the Veteran's account of the stressor incident. 38 C.F.R. § 3.304(f)(5). Stated alternatively, corroboration of the claimed assault dated contemporaneously with the incident is not required to substantiate the incident. Instead, examples of such evidence include, but are not limited to: records from law enforcement authorities; rape crisis centers; mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. 38 C.F.R. § 3.304(f)(5). For personal assault PTSD claims, an after-the-fact medical opinion can serve as the credible supporting evidence of the stressor. 38 C.F.R. § 3.304(f)(5). Under this regulation, VA may submit any evidence it receives to a mental health professional for an opinion as to whether a personal assault occurred. Stated otherwise, in a claim of service connection for a psychiatric disorder that is alleged to have been caused by a personal assault, the absence of historical validation of the in-service incident is not necessarily fatal to the claim. Rather, a VA mental health care provider may express an opinion as to whether, given all evidence of record, the claimed in-service assault occurred." Although the cited regulation provides that the evidence in support of a finding of the claimed stressor relates to sexual assault (i.e., rape crisis centers, pregnancy tests, tests for sexually transmitted diseases, etc.), the balance of the regulation does not limit its application in this respect. Instead, the language indicates that the regulation applies to "in-service personal assault." Further, the law requires that interpretive doubt be resolved in the Veteran-claimant's favor. See Brown v. Gardner, 513 U.S. 115, 118, 115 S.Ct. 552, 555, 130 L.Ed.2d 462 (1994) ("interpretive doubt is to be resolved in the veteran's favor"). The Veteran has been diagnosed with PTSD by an examining VA physician, based on his subjective account of the occurrence of a personal assault. In this circumstance, the Board is compelled to grant the benefit. Recent VA treatment records reflect diagnoses of and treatment for PTSD, chronic, mild to moderate; depressive disorder, not otherwise specified, due to general medical condition that is chronic pain; and generalized anxiety disorder. The Axis I diagnoses on VA examination in September 2013 were PTSD and depressive disorder, not otherwise specified. Even if service connection for depressive disorder or generalized anxiety disorder were to be established, no additional benefit would be due to the Veteran. The rating criteria for PTSD (Diagnostic Code 9411), major depressive disorder (Diagnostic Code 9434), and generalized anxiety disorder (Diagnostic Code 9400) are exactly the same under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. The September 2013 VA examiner indicated by marked box that it was possible to differentiate between what symptoms were attributable to each diagnosis; however, in listing the symptoms attributable to each diagnosis, she reported sleep problems in regard to both depression and PTSD. She indicated that the Veteran had social isolation as a result of his depression and described avoidance of most social situations as a symptom of his PTSD. These comments reflect that there is duplicative or overlapping symptomatology among the diagnosed psychiatric disorders. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Federal Circuit has held that two defined diagnoses constitute the same disability for purposes of section 4.14 if they have overlapping symptomatology. See Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009). Accordingly, a separate discussion as to the Veteran's psychiatric disorders other than PTSD is unnecessary. The RO will assign an appropriate effective date and disability rating. Analysis - Low Back Condition A three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013). The Veteran has, at times, asserted that he entered service with a pre-existing congenital back condition which was aggravated during service. During a January 2001 VA mental disorders examination, he reported a congenital problem with his spine. In his September 2010 claim for service connection, he asserted that he had a birth defect affecting his back which was aggravated by boot camp training. In an April 2011 statement, the Veteran reported that he was physically abused during service, including being stomped on and having ammunition cans thrown at him. He stated that doctors he had seen for his back had told him that his condition could be congenital or from a trauma situation, but could not say for sure. He reiterated in August 2011 that his doctors had told him that they could not tell for sure if his back condition was from trauma or congenital. In a statement submitted with his December 2011 notice of disagreement (NOD), the Veteran stated that his first trauma to his back was during service or a birth defect which he became aware of as a result of X-rays taken in 1985 for a pre-employment physical. The Federal Circuit has distinguished between those cases in which the preexisting condition is noted upon entry into service, and those cases in which the preexistence of the condition must otherwise be established. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); see also 38 U.S.C. § 1111 (presumption of sound condition). In a case where there is no preexisting condition noted upon entry into service, the Veteran is presumed to have entered service in sound condition, and the burden falls to the government to demonstrate by clear and unmistakable evidence that (a) the condition preexisted service and (b) the preexisting condition was not aggravated by service. 38 U.S.C. § 1111; Wagner, 370 F3d. at 1345. The Court has held that the presumption of soundness does not apply to congenital defects because such defects are not considered diseases or injuries within the meaning of 38 U.S.C.A. §§ 1110 and 1111. See Quirin v. Shinseki, 22 Vet. App. 390, 396-97 (2009). Although the claimant is competent in certain situations to provide a diagnosis of a simple condition, such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions, such as concerning a form of cancer. See Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Despite the fact that the Veteran has, at times, reported that his low back condition is congenital, the issue of whether or not his low back condition is a congenital condition is a complex medical question. Therefore, the Veteran is not competent to provide evidence on this matter. The Veteran has reported that doctors told him that his low back condition could be congenital, as reported in April and August 2011 statements; however, unsupported assertions of statements from a physician do not, in and of themselves, constitute medical evidence required to substantiate a service connection claim. See Robinette v. Brown, 8 Vet. App. 69, 77 (1995). Moreover, the Veteran stated that his doctors had told him that his condition could be congenital, but were not sure. Following an April 2012 evaluation in the VA orthopedic surgery clinic, the Veteran asked that his chart be corrected to note that a sergeant had stomped on his back during service; that his spine issue was not congenital; and that the 1969 injury was the result of spondylolysis. The physician assistant commented in May 2012 that she had discussed the case with a physician and, in most cases, spondylolysis is a stress injury many years old. She stated, "It is not possible to correlate with any specific trauma. Based on his MRI and X-rays this does not appear to be a congenital pathology." The May 2012 opinion that the Veteran's low back condition does not appear to be congenital is competent, was based on examination of the Veteran and review of imaging studies, and weighs against the assertion that the Veteran had a congenital low back condition which existed prior to entry into service. A low back condition was also not noted upon entry into service. On enlistment examination in June 1969, clinical evaluation of the spine was normal. Accordingly, presumption of soundness applies as to the Veteran's claimed low back condition. Therefore, if the Board is to find that the presumption of soundness is rebutted and that the Veteran's low back condition preexisted service, it must find (1) that clear and unmistakable evidence shows that the low back condition preexisted service; and (2) that clear and unmistakable evidence shows that his low back condition was not aggravated by service. Horn v. Shinseki, 25 Vet.App. 231, 234 (2012). In his June 1969 Report of Medical History at enlistment, the Veteran denied recurrent back pain. He underwent a physical screening examination in July 1969, the day after his entry into active duty, and was found to be physically fit to undergo military training, with no defects noted. In a form completed in January 1987 in conjunction with his claim for SSA disability benefits, the Veteran reported that his back problems first bothered him in November 1986. In an October 1988 SSA form, the Veteran reported that he was disabled because of lower back pain and his condition had first bothered him in June 1986. In another form, completed in June 1989, the Veteran reported that his low back pain had first bothered him in December 1987, noting that he had a back problem but did not take action for some time. In a November 2000 orthopedic examination performed in conjunction with his claim for SSA benefits, the Veteran denied any specific trauma which started his problems, but reported that his back problems started when he was 16 or 17 (so prior to entry into active duty, as the Veteran was 19 at enlistment). X-ray revealed severely narrowed disc space at L5-S1 with grade 2 spondylolisthesis. The diagnosis was chronic back pain by history. The physician commented that the Veteran's story and physical findings did not correlate well. Despite this November 2000 report of back problems prior to service, in light of his June 1969 denial of recurrent back pain and the January 1987, October 1988, and June 1989 reports of back problems first bothering the Veteran in the mid to late 1980s, the evidence does not clearly and unmistakably establish that the low back condition pre-existed service. As there is not clear and unmistakable evidence establishing that the Veteran had a pre-existing low back condition at entry into service, he is presumed sound at entrance. Consequently, the theory of in-service aggravation will not be further addressed and the claim becomes one for direct service connection. Recent VA treatment records reflect that the Veteran has a current low back condition. For example, an April 2012 VA orthopedic surgery clinic note reports that X-ray revealed severe degenerative disk changes at L4-5 and L5-S1, probably bilateral pars defect at L4, and a severe anterolisthesis of L5 on S1. MRI revealed similar findings, with moderate anterolisthesis L5-S1. Bilateral pars defect in the anterolisthesis had increased since the 2001 MRI. There were also degenerative changes at L5-S1, and mild disk bulging and moderate facet arthropathy with foraminal stenosis at L4-5. The assessment was lumbar spondylosis and stenosis with spondylolisthesis. Thus, the first element of the service connection claim, a current disability, is satisfied. Regarding in-service injury, the Veteran has reported incurring a back injury when he was stepped on by a sergeant during training. The Veteran is competent to report in-service injury. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1991). However, in light of his inconsistent statements, the Board finds his reports of an in-service injury to the back not to be credible. See Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). While, as discussed in the analysis of the claim for service connection for a psychiatric disorder, the Veteran suffered a personal assault in service, which the Board finds to be credible, the record does not support that this assault/abuse included injury to the back. Despite recent reports that his in-service assault included injury to the back when he was stomped on by a sergeant, during private treatment in January 1987, the Veteran denied a history of acute back injury, but reported that he had been employed doing heavy work for years and described frequent episodes of back pain lasting for several days. In a November 2000 orthopedic examination performed in conjunction with his claim for SSA benefits, the Veteran denied any specific trauma which started his problems, but reported that his back problems started when he was 16 or 17. In light of his earlier denials of trauma to the back, the Board finds the Veteran's assertions of in-service back injury, made in conjunction with his current claim for service connection, not credible. Even if the report of in-service injury to the back was accepted as credible, service connection would still not be warranted as there is no competent, probative evidence of a nexus between the current low back condition and service. Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard. See Walker, 708 F.3d at. When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Walker, 708 F.3d at 1338. Thus, if the claimant does not have one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and the "nexus" requirement of the three-element test must be met. Id. at 1338-39. A December 2011 MRI documents degenerative changes in the lumbar spine. Arthritis is a chronic disease listed in section 3.309(a); therefore, the provisions of subsection 3.303(b) for chronic disabilities apply. Walker, 708 F.3d at 1338. The Veteran has, at times, reported a continuity of symptomatology of back problems since service. For example, during VA treatment in August 2011 he reported lower back pain "ever since the military." He presented to the VA emergency room in July 2012 with complaints of acute on chronic back pain and reported that he had been dealing with his current back pain for 42 years since a service injury. Nevertheless, the assertions of a continuity of symptomatology are outweighed by the evidence of record. As stated above, in January 1987, October 1988, and June 1989 SSA forms, the Veteran reported that his back problems first bothered him in November 1986, June 1986, and December 1987, respectively. A December 2000 VA physical therapy evaluation reflects that the Veteran complained of low back pain for several years with a recent increase in symptoms. He stated that he was involved in motor vehicle accidents in 1989 and 1992 and had had progressive low back pain since that time. In November 2001, the Veteran presented to the Albany VAMC and described a long history of low back pain since 1986 after a motor vehicle accident which was treated relatively conservatively until a 1998 work-related injury. During VA treatment in March 2004, the Veteran reported back pain for 13 years. In light of the inconsistencies in his statements regarding the history of his low back problems, the Veteran's assertions of a continuity of symptomatology of back problems since service are not credible. Thus, service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) is not warranted. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). The relationship between current low back condition and service, however, must be established by evidence of a nexus. See Walker, 708 F.3d at 1338-39. Here, there is simply no competent, probative evidence of a nexus between the Veteran's current low back condition and service. A note from May 2012 reflects that the Veteran called the physician assistant who had evaluated him in the VA orthopedic surgery clinic with questions regarding his low back condition. The Veteran reported that he "was told again through the laser institute that his issue is not congenital and is from trauma." He asked what could have caused his condition if it was not congenital, and recalled the in-service incident he had previously described. The physician assistant responded that it would be difficult to tell when an event occurred unless the Veteran had serial imaging and she suggested that his best option would be to return to the clinic to see the surgeon. In an addendum dated later that month, the physician assistant commented that she had discussed the Veteran's case with a physician and, in most cases, spondylolysis is a stress injury many years old. She stated, "It is not possible to correlate with any specific trauma." In November 2012, the Veteran spoke to the attending physician at the VA orthopedic surgery clinic. The physician stated, "I do think I have been pretty clear about my opinion and have explained this to him multiple times now." The Veteran's question was whether his lumbar spine condition could be caused by an injury in 1969 when a sergeant stomped on his back. The physician stated he had explained many times, and explained again, that the Veteran had spondylolysis with lysthesis at L5-S1 and spondylolysis is a stress injury, not a traumatic fracture caused by one specific traumatic event. The physician stated, "It is not possible to correlate this kind of injury to one specific traumatic event unless there are x rays before and after trauma." He concluded by stating that he felt he had explained this to the Veteran multiple times and did not have anything further to add. There is no indication that X-rays documenting the condition of the Veteran's back prior to and after service exist; rather, the Veteran stated in December 2011 that no X-rays were taken for pre-enlistment, after being received at Parris Island, or on the date of his discharge from service. In a January 2012 statement, the Veteran reported that, shortly after discharge from service, C.B. had taken him to the emergency room for acute back pain and to the mental health clinic for depression and anxiety and "said this is all service related and referred me to a Veteran Service Officer (VSO)." It is not clear that the Veteran was reporting that he was told that his back pain was related to service, or who made such statement. Regardless, even if the Veteran intended to report that the clinician who evaluated his back pain shortly after service related this to his service, such report of what a physician told him does not constitute medical evidence required to substantiate a service connection claim. See Robinette, 8 Vet. App. at 77. Actual emergency room records regarding treatment for a back condition shortly after separation from service have not been associated with the claims file. While, in a statement submitted in June 2012, C.B. reported that she had taken the Veteran to the emergency room for his back, the fact that the Veteran received treatment for his back, alone, does not establish a nexus between his current low back condition and service. In an October 2012 statement, the Veteran reported that the clinicians at the VA orthopedic surgery clinic told him that his back condition was not congenital, but had come from a trauma event; although they could not pin point to a specific date due to being so old. He added that he had asked whether stomping on his back could have caused his condition, and they both stated it was possible, but failed to put it in their report. The Veteran's report that his VA clinicians told him that it was possible that stomping on his back could have caused his current condition does not establish the required nexus between the current low back condition and service. See Robinette, 8 Vet. App. 77. In any event, the Veteran's report is outweighed by the more recent November 2012 record in which the attending physician clearly stated that spondylolysis is a stress injury, not a traumatic fracture caused by one specific traumatic event and it would not be possible to correlate this kind of injury to one specific traumatic event unless there are X-rays before and after trauma. As stated, there is no indication of such imaging in this case. In the absence of a nexus between the Veteran's current low back condition and service, service connection is not warranted. The Veteran has not presented or identified any existing medical opinion that, in fact, supports the claim for service connection. Service connection can be granted for certain diseases, including arthritis, if manifest to a degree of 10 percent or more within one year of separation from active service. Such diseases shall be presumed to have been incurred in service even though there is no evidence of disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Here, there is no evidence of degenerative changes in the lumbar spine manifested to a compensable degree within one year of separation from service. The earliest X-ray of record is a January 1987 study revealing grade 2 spondylolisthesis with bilateral spondylolysis of L5 anteriorly on S1 and spina bifida occulta. The other vertebral bodies, intervertebral disc spaces and posterior elements were unremarkable. The first diagnosis of degenerative joint disease (DJD) of the lumbar spine is found in a November 2000 VA treatment record and the first radiological evidence of degenerative changes in the lumbar spine is documented on a December 2011 MRI. Thus, service connection is not warranted on a presumptive basis. In addition to the medical evidence, the Board has considered the Veteran's contention that he has a current low back condition related to service. As previously stated, although he is competent in certain situations to provide a diagnosis of a simple condition, the Veteran is not competent to provide evidence as to more complex medical questions. See Woehlaert; Colantonio, supra. The Veteran does not have or claim to have any specialized knowledge in the field of medicine. The Board therefore finds that the etiology of his current low back condition is beyond his competence. Moreover, the question of etiology of this condition is complex in nature. Therefore, to the extent he has asserted that he has a low back condition related to service, the Board finds such assertions to be of little probative value. As the preponderance of the evidence is against the claim service connection for a low back condition will be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for PTSD is granted. Service connection for a low back condition is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs