Citation Nr: 1309815 Decision Date: 03/22/13 Archive Date: 04/01/13 DOCKET NO. 07-37 886 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a neurologic bilateral leg disability, to include as manifested by pain and numbness in the lower extremities, to include as secondary to a low back disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J.M. Seay, Associate Counsel INTRODUCTION The Veteran had active service from February 1976 to July 1984. These matters come before the Board of Veterans' Appeals (Board) from a March 2007 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Wichita, Kansas. These matters were previously before the Board in February 2010 and May 2012. The case has now been returned to the Board for further review. FINDINGS OF FACT 1. The earliest clinical evidence of a post service back disability is in 2006, approximately 20 years after separation from service. 2. The most probative and credible evidence is against a finding that the Veteran has a current low back disability related to active service. 3. The most probative and credible evidence is against a finding that the Veteran has a neurological disability of the lower extremities that is related to active service or a service-connected disability. CONCLUSIONS OF LAW 1. A low back disability was not incurred in, or aggravated by, active service and may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). 2. A neurologic bilateral leg disability, to include as manifested by pain and numbness in the lower extremities, was not incurred in, or aggravated by, active service, and was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Duty to Notify Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and 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. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court in Dingess/Hartman held that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Upon receipt of an application for "service connection," therefore, VA is required to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, it will assist in substantiating or that is necessary to substantiate the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In correspondence to the Veteran in October 2006, VA informed him of what evidence was required to substantiate the claims, of his and VA's respective duties for obtaining evidence, and of the criteria pertaining to the assignment of a disability rating and effective date as the Court required in Dingess/Hartman. Because VCAA notice in this case was completed prior to the initial AOJ adjudication denying the claims, the timing of the notice complies with the express requirements of the law as found by the Court in Pelegrini. The VCAA requires that the duty to notify is satisfied, and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996). The Board finds the VCAA notice requirements have been met in this case. Duty to assist With regard to the duty to assist, the claims file contains the Veteran's service treatment records (STRs), VA medical treatment records, and the Veteran's statements in support of his claims. In February 2010, the Board remanded the Veteran's case for additional development to include sending the Veteran a notification letter requesting that he furnish the names, addresses, and dates of treatment of all medical providers from whom he has received treatment for a low back disability and/or bilateral leg neurologic disability since his discharge from service. The Veteran was sent a notification letter in March 2010 that was returned as undeliverable. However, the Veteran was subsequently sent a notification letter in May 2012 to his new address, which included VA Forms 21-4142. The Veteran did not respond. Therefore, as the Veteran was provided an opportunity to identify medical records, but did not respond, the AMC substantially complied with the February 2010 remand. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In May 2012, the Board remanded the Veteran's case to contact the Veteran and ask that he identify the approximate month of treatment at the Landstuhl, Germany medical facility in 1979 for an alleged back injury due to a fall from a vehicle. The Board also asked that the Veteran be provided VA Forms 21-4142 for all facilities in which he has been incarcerated in which he was medically examined and for all employers who may have a record of an employment physical, to include his employment as a truck driver. As noted above, the Veteran was sent a notification letter in May 2012 in accordance with the May 2012 remand directives. The Veteran did not respond. The Board recognizes the Veteran's representative's request that the case be remanded to obtain records from the Landstuhl, Germany medical facility. However, as noted above, the Veteran did not respond with any approximate dates of treatment so that a meaningful search could be conducted. VA's duty to assist is not a one-way street. If the Veteran wishes help, he cannot passively wait for it in those circumstances where his own actions are essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, the Board finds that the May 2012 remand directives were substantially completed and a remand for corrective action is not required. Stegall, id; Dyment, id. The Board has carefully reviewed the statements and concludes that there has been no identification of further available evidence not already of record for which VA has a duty to attempt to obtain. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a further duty to obtain. VA examinations and opinions with respect to the issues on appeal were obtained in June 2010, June 2011, and February 2012. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In February 2010, the Veteran's case was remanded, in part, to provide a VA examination. The Veteran was provided a VA examination in June 2010. The VA examiner provided a positive nexus opinion, but did not provide any rationale for the opinion. As a result, the Veteran was provided another VA examination in June 2011, but no opinion was provided. An addendum to the report was provided in February 2012 by the examiner who conducted the June 2011 VA examination. The examiner offered a positive nexus opinion with supporting rationale. The examiner stated that the Veteran strained his back in May 1976 when moving a 55 gallon drum. In addition, the Veteran described falling out of a vehicle onto his back when he was deployed to Germany in 1979. The examiner found that the latter event was not documented in the claims file, but that the Veteran's account appeared credible. The examiner referenced an article from a medical journal and stated that "exposure to injuries and mechanical stress on the back is thought to increase the incidence of low back pain and degenerative changes." Based on this, the examiner opined that the Veteran's current lumbar spine condition was more likely than not due to injuries during military service. These include the one event described in the claims file and a second that was credibly described by the Veteran, but apparently not addressed in the claims file. In the May 2012 remand, the Board determined that the rationale provided for the opinion was not adequate because the rationale was not substantiated as specific to the Veteran. As will be discussed in further detail below, the Board does not find the opinion to be probative in this case. However, while finding that the opinion is not probative, it is nonetheless adequate for adjudication purposes in that it substantially complied with the prior February 2010 remand. In this respect, the examiner reviewed the claims file and offered an opinion with supporting rationale. That the Board has found other evidence to be more persuasive does not render the opinion as a whole inadequate or in noncompliance with the Board's remand. Therefore, the Board finds the opinion is adequate and the February 2010 remand directives were substantially completed. See Barr, id; Dyment, id. Finally, the record shows that the Veteran was provided a VA examination in June 2011 with respect to his claim for service connection for a neurologic bilateral leg disability. The examiner opined that the numbness and tingling of the left arm and both legs was more likely than not due to diabetes. The examiner did not provide a rationale. However, in an addendum to the report dated in November 2011, the examiner provided a supporting rationale for the opinion. The examiner explained that the numbness and tingling experienced by the Veteran was unlikely to be because of low back pain, which could cause radiculopathy and pain of either lower extremity, but not his left arm. In addition, his straight leg raise test was negative (a positive test would be expected if radiculopathy were present). The Board notes that the examiner did not state whether the Veteran's disability was caused or aggravated by his low back disability. However, the examiner explained that the Veteran's disability was related to his nonservice-connected diabetes. Furthermore, the Veteran is not service connected for a low back disability and, therefore, corrective action would not assist the Veteran in this case. See generally Sabonis v. Brown, 6 Vet. App. 426 (1994) (When the law and not the evidence is dispositive, a claim for entitlement to VA benefits should be denied or the appeal to the Board terminated because of the absence of legal merit or the lack of entitlement under the law). Therefore, the examiner's opinion is adequate and the Board's February 2010 remand directives have been substantially completed. See Stegall, id; Dyment, id. In addition, the Board is aware that the examiner did not specifically provide an opinion as to whether a neurologic disability is causally or etiologically related to active service. However, as noted above, the examiner provided an opinion relating the Veteran's neurologic symptoms to his diabetes. Furthermore, the service treatment records are absent for any indication of a neurologic disability and there is no clinical evidence of neurological symptoms until decades after separation from active service. Indeed, the Veteran himself has not reported that he experienced neurologic symptoms during active service. As there is no event, injury, or disease in service to which a current disability could be related, the Board finds that a VA opinion as to direct service connection is unnecessary. 38 C.F.R. § 3.159(c)(4). 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 his claims. Legal criteria Service connection - in general Service connection is warranted if it is shown that a Veteran has a disability resulting from an injury incurred, or a disease contracted, in active service or for aggravation of a pre-existing injury or disease in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). In Robinson v. Shinseki, 312 Fed. Appx. 336 (2009), the Court held that, in some cases, lay evidence will be competent and credible evidence of etiology. Whether lay evidence is competent in a particular case is a question of fact to be decided by the Board in the first instance. The Court set forth a two-step analysis to evaluate the competency of lay evidence. First, Board must first determine whether the disability is the type of injury for which lay evidence is competent evidence. If so, the Board must weigh that evidence against the other evidence of record-including, if the Board so chooses, the fact that the Veteran has not provided any in-service record documenting his claimed injury - to determine whether to grant service connection. The Board observes that this Federal Circuit decision is nonprecedential. However, see Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) [a non-precedential Court decision may be cited "for any persuasiveness or reasoning it contains"]. The Board believes that if Bethea applies to the utility of Court decisions, it surely applies to the utility of a decision of a superior tribunal, the Federal Circuit. 557 F.3d 1355 (Fed. Cir. 2009). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Low Back Disability The Veteran avers that he has a low back disability that is related to active service. The record reveals that the Veteran has a current disability. The June 2011 VA examination report includes diagnoses of degenerative disc disease and osteoarthritis of the lumbar spine. The service treatment records show that the Veteran complained of injuring his back after lifting a heavy 55 gallon barrel on his shoulder in May 1976. The assessment was listed as "rule out pulled latissimus dorsi." The examining physician instructed the Veteran to use Tylenol. The remaining service treatment records are absent for any follow-up treatment or complaints of back pain. The Veteran has also averred that he fell out of a vehicle in 1979 and was hospitalized in Landstuhl, Germany. In May 2012, the Veteran was given the opportunity to provide his dates of treatment at the Landstuhl, Germany medical facility so that records could be requested on his behalf. The Veteran did not respond to the May 2012 letter. The service treatment records do not reflect any physical profile for the Veteran's back and the records dated in 1979 (when the Veteran has alleged treatment) do not reveal any complaints or documentation of back pain. The Veteran was treated in May 1979, August 1979, September 1979, and December 1979, and did not mention any back injury or complaints. In addition, the Veteran also sought treatment in 1980, 1981, 1982, and several times in 1983, and did not mention or seek treatment for complaints related to the back. The separation report of medical history completed in 1984 shows that the Veteran denied having or ever having recurrent back pain. The earliest clinical evidence for a back disorder is in 2006, more than 20 years after the Veteran's separation from active service. Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (ruling that a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service resulting in any chronic or persistent disability). In an October 2006 VA treatment record, the Veteran reported a history of a back injury with a possible fractured disk in 1979 while in the Army. Since that time, he has had difficulty with chronic low back pain. In a February 2007 administrative note, the nurse practitioner noted that the Veteran reported that he had chronic low back pain that he said began while he was in the military. It was noted that the magnetic resonance imaging (MRI) study revealed an impression of bilateral L5-S1 severe neural foraminal narrowing. The nurse practitioner stated that the injury he had in the military could have been the original injury causing this condition. The Board does not find the opinion to be probative. The nurse practitioner did not note the injury complained of by the Veteran, did not appear to review the service treatment records which do not reflect chronic back pain, and used speculative language. The use of equivocal language makes a statement by an examiner speculative in nature. See Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by a physician is too speculative). It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). The Veteran was provided a VA examination in June 2010. The Veteran reported that the onset of his back pain was in 1979. He reported that he was in Germany and fell approximately five feet, landing on his back. He described the pain as an excruciating pain. The Veteran noted that his initial injury was lifting a 180 pound object while in the military and that he was hospitalized but did not undergo surgery at Landstuhl, Germany. The impression was listed as lumbar spine with degenerative disc disease, degenerative arthritis that is at least as likely as not service-related. The examiner did not provide a rationale for the positive nexus opinion. The Veteran was provided another VA examination in June 2011. The claims file was reviewed. The Veteran reported that while deployed to Germany, he fell out of a vehicle onto his back. He had a profile for reduced activity over 7 days and gradually recovered. He had relatively minor back pain for a period of years. Since approximately 2006, he has had severe back pain with imaging showing degenerative joint disease. The Veteran was diagnosed with degenerative joint disease of the lumbar spine. An opinion as to etiology was not provided. An addendum opinion was obtained in February 2012 by the examiner who conducted the June 2011 VA examination. The claims file was reviewed. The examiner noted that the Veteran strained his back in May 1976 while moving a 55 gallon drum. In addition, the Veteran described falling out of a vehicle onto his back, while deployed to Germany in 1979. Afterwards, he reported that he had a profile for reduced activity over 7 days and gradually recovered. The examiner noted that he did not find the latter event documented in the claims file, but that the Veteran's account appeared credible to him. The examiner referenced a medical journal and noted that "exposure to injuries and mechanical stress on the back is thought to increase the incidence of low back pain and degenerative changes." Based on this, the examiner opined that the Veteran's current lumbar spine condition was more likely than not due to injuries during military service. These include the one event that was described in the claims file and a second event that was credibly described by the Veteran but apparently not addressed in the claims file. In reviewing the nexus evidence in this case, the Board does not find that the evidence to be probative of a nexus relationship between the Veteran's current low back disability and any in-service event, disease, or injury. As noted above, the Board determined that the February 2007 opinion was speculative and, therefore, not probative. The Board recognizes the positive opinion provided by the June 2010 VA examiner; however, there was no rationale provided for the opinion - rendering the opinion inadequate and not probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The February 2012 addendum to the June 2011 VA examination report reflects a positive nexus opinion with supporting rationale. The examiner found that the Veteran's account regarding a fall off of a vehicle in 1979 during active service to be credible and provided a positive nexus opinion based in part on this injury. However, the Board does not find the examiner's opinion to be probative. First, the examiner quoted a medical journal article in noting that the exposure to injuries and mechanical stress on the back is thought to increase the incidence of low back pain and degenerative changes. This rationale is not specific to the Veteran in this case. In addition, the Board notes that the Veteran reported during his June 2010 and June 2011 VA examinations and an October 2006 treatment note that his chronic pain began after the 1979 in-service injury when he fell off of a vehicle and was hospitalized for one week (not his 1976 injury documented in the service treatment records). The Board finds that the Veteran is not credible with respect to his reports of a 1979 in-service injury or the chronicity of his pain. The service treatment records show that the Veteran complained of pulling his back in 1976 and the examining physician noted an assessment of "rule out pulled latissimus dorsi." As noted above, the Veteran mentioned several times including during two VA examinations that his chronic pain began after the alleged 1979 injury. The remaining service treatment records are absent for any indication or documentation pertaining to the Veteran's back, indicating that the May 1976 injury was acute and transitory. Although the Veteran reported a subsequent injury in 1979 involving hospitalization and a physical profile for 7 days, the records do not reveal any such injury. The Veteran was given the opportunity to submit his dates of hospitalization, but did not respond to the Board's request. The Board does not find it reasonable that the Veteran would be hospitalized for such a serious injury, yet, when he was treated from 1979 through 1983, he would not mention any injury or complaints related to his back. Indeed, the separation report of medical history dated in 1984 shows that the Veteran denied having or ever having recurrent back pain. Taking into consideration all of the evidence of record, including the service treatment records, the Veteran's report of medical history, and the decades long absence of any back disorder between active service and 2006, the Board finds that the evidence weighs against service connection. It is entirely within the Board's province to give more probative weight to certain pieces of evidence than others, so long as the Board provides adequate reasons and bases. See Schoolman v. West, 12 Vet. App. 307, 310-311 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995); see Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). The Board recognizes the Veteran's contentions that his current low back disability is related to active service. However, the Board finds that the issue of etiology of a low back disability, diagnosed as degenerative joint disease and degenerative disc disease, to be a complex medical question that the Veteran is not competent to address. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). To the extent that he has reported that his disability has been chronic since service, the Veteran, as a lay person, is competent to report on matters observed or within his personal knowledge, including observable symptoms such as pain. See 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013) (finding that continuity of symptomatology under 38 C.F.R. § 3.303(b) only applies to those conditions recognized as chronic under 38 C.F.R. § 3.309(a)). However, the Board does not find the Veteran's account regarding the onset and continuity of his symptomatology to be credible. The Veteran stated his belief that his disability had its onset during active service and that he has had intermittent back pain for decades, which became more serious in 2006. As noted above, the service treatment records show that the Veteran complained of a back injury in 1976. However, the evidence indicates that the injury was acute, not chronic. As noted above, the remaining service treatment records are absent for any complaints or documentation related to the Veteran's back. Indeed, the Veteran reported to the June 2010 and June 2011 examiners that a 1979 injury resulted in chronic back pain. The records do not reveal a 1979 injury and the subsequent service treatment records are absent for any complaints or treatment pertaining to the Veteran's back. The report of medical history completed in 1984 shows that the Veteran denied having or ever having recurrent back pain. In addition, although the Veteran reported being hospitalized in 1979 during active service, he did not respond to the notification letter requesting hospitalization dates so that records could be requested to verify his alleged hospitalization. Based on the above and the Veteran's inconsistent statements (see separation report of medical history), the Board finds that service connection based on continuity of symptomatology is not warranted. In this case, service connection is not warranted because the Board finds that the third requirement has not been met. The Board has found that the medical opinions are not probative of a relationship between the Veteran's current disability and his period of active service and the evidence regarding continuity of symptomatology of such a disability since service is not credible. The Board has attributed significant probative value to the Veteran's statements contemporaneous to service, as shown on the separation report of medical history, the absence of continued complaints in the service treatment records following the 1976 documented injury, and the decades long gap between the Veteran's service and the first clinical evidence of the Veteran's disability. Based on the foregoing, the Board finds that the preponderance of the evidence is against a grant of service connection. 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); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Finally, certain chronic diseases, including arthritis, may be presumed to have occurred in service if manifested to a degree of 10 percent within one year of service discharge. 38 C.F.R. §§ 3.307, 3.309(a). There is no evidence that the Veteran was diagnosed with arthritis within one year of service discharge. Therefore, the presumption does not apply. Neurologic disability Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The Veteran avers that his neurologic disability of the lower extremities is related to his low back disability. In his notice of disagreement, he stated that his neurologic condition was secondary to his lower back condition. The Veteran has provided general statements explaining that his "conditions" were caused by military service. For purposes of clarity, the Board notes that service connection for an orthopedic bilateral leg condition was denied in the February 2010 Board decision. To warrant service connection on a secondary basis, there must be a service-connected disability. As noted above, service connection is not warranted for a low back disability. Even so, the most probative evidence has related the Veteran's neurological disability to a nonservice-connected disability. In this respect, the Veteran was provided a VA examination in June 2011. The examiner stated that the Veteran's numbness and tingling of the left arm and both legs was more likely than not due to diabetes. In a November 2011 addendum to the June 2011 examination report, the examiner again stated that the Veteran has numbness and tingling of the left arm and both legs, which was more likely than not due to diabetes. The examiner explained that the symptoms were unlikely to be because of his low back pain, which can cause radiculopathy and pain of either lower extremity, but not his left arm. In addition, the examiner stated that the Veteran's straight-leg raise was negative (a positive test would be expected if radiculopathy were present). The Board finds that the examiner's opinion is probative as the examiner described the symptoms of the Veteran's disability and explained why the Veteran's symptoms were more likely due to diabetes, addressing the findings specific to the Veteran. See Nieves-Rodriguez v. Peake, id. The Board recognizes the Veteran's statements that his neurologic disability is related to his low back disability. However, as noted above, the Veteran has not been service connected for a low back disability and, therefore, service connection on a secondary basis cannot be awarded. In addition, 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, i.e., the etiology of a neurologic disability and its relationship to a low back disability, 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)." The Veteran has not been shown to have had any medical training. After considering all the evidence of record, the Board finds that the preponderance of the evidence is against the claim for service connection for a neurologic disability on a secondary basis. As such, the benefit of the doubt doctrine is not for application and the claim is denied. See 38 U.S.C.A. § 5107 (b) (West 2002). The Board will also address whether service connection is warranted on a direct-incurrence basis. The RO adjudicated the Veteran's claim on a direct and secondary basis and, therefore, no prejudice results to the Veteran in proceeding with adjudication of direct service connection. The Veteran has stated that his neurologic disability is secondary to a low back disability. However, he has also provided general statements that his conditions are related to active service. The service treatment records reflect that the Veteran had difficulties with his lower extremities, including his feet. However, there is no indication of any neurological problems or complaints. As noted above, the claim for service connection for a bilateral orthopedic disability was denied by a February 2010 Board decision. In the report of medical history completed in 1984, the Veteran denied having or ever having neuritis. Following separation from active service, the first clinical evidence of neurological symptoms are in VA treatment records dated in 2006, approximately twenty years after the Veteran's separation from active service. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). As noted above, the Veteran's neurologic symptoms have been related to his nonservice-connected diabetes, not his period of active service. In a November 2011 addendum to the June 2011 examination report, the examiner stated that the Veteran has numbness and tingling of the left arm and both legs, which was more likely than not due to diabetes. The Board finds that the examiner's opinion is probative as the examiner explained the medical findings supporting this conclusion. In this case, the only evidence relating the Veteran's disorder to active service are his own general statements relating his conditions to active service. He has not reported that he experienced neurologic symptoms during active service. Although the Veteran is competent to provide statements regarding lay-observable symptoms, he is not competent to provide an opinion as to the etiology of his neurologic disability. The Board acknowledges that 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. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Moreover, the Board is mindful that competent medical evidence is not necessarily required where the determinative issue in a case involves medical causation or a medical diagnosis. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); see also Barr v. Nicholson, 21 Vet App 303 (2007). However, the Board finds that the Veteran's general statements regarding etiology are not competent. The issue of etiology of a neurologic disability is a complex medical question, which the Veteran is not competent to address as he has not been shown to have had any medical training. With respect to any continuity of symptomatology, the Federal Circuit recently held that the continuity of symptomatology under 38 C.F.R. § 3.303(b) only applies to those conditions recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). The Veteran's claimed neurological disability is not among the diseases recognized as chronic. 38 C.F.R. § 3.309(a). Therefore, service connection is not warranted on the basis of continuity of symptomatology. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim for direct service connection. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a neurologic bilateral leg disability, to include as manifested by pain and numbness in the lower extremities, to include as secondary to a low back disability, is denied. ____________________________________________ U.R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs