Citation Nr: 1608852 Decision Date: 03/04/16 Archive Date: 03/09/16 DOCKET NO. 10-02 581 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for a low back disability. 3. Entitlement to service connection for a right thumb disability. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD G.R. Waddington, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1975 to May 1979. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the VA Regional Office (RO) in Huntington, West Virginia. October 2008 and March 2010 Rating Decisions. The RO in Jackson, Mississippi currently has jurisdiction over this appeal. The Veteran testified before the undersigned at a July 2011 video-conference hearing. The undersigned held the case open for 30 days in order for the Veteran to submit additional evidence. A hearing transcript is in the electronic claims file. In January 2012, the Board determined that new evidence had been associated with the claims file that was material to the claims on appeal. The Board reopened the claims and remanded them for further development. See January 2012 Board Decision. In October 2012, the RO granted service connection for tinea cruris and folliculitis of the right thigh. In September 2014, the Board denied service connection for bilateral hearing loss and for a chest disorder. Consequently, the issues of entitlement to service connection for a skin disorder, bilateral hearing loss, and a chest disorder are no longer on appeal and are not addressed in this decision. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). This appeal was processed using the Virtual VA paperless claims processing system. Any future consideration of this case must account for the electronic record. FINDINGS OF FACT 1. The Veteran's tinnitus relates to in-service noise exposure. 2. The Veteran's back disability does not relate to service, to include an in-service injury due to a tank accident. 3. The Veteran's right thumb disability does not relate to service, to include an in-service injury due to a tank accident. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus have been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2015). 2. The criteria for service connection for a low back disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2015). 3. The criteria for service connection for a right thumb injury have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has satisfied its duties under the Veteran's Claims Assistance Act of 2000 to notify and assist. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2015). Because the Veteran's service connection claim for tinnitus is granted, any error related to the VCAA with respect to this claim is harmless. See id; Shinseki v. Sanders, 556 U.S. 396, 407, 410 (2009). A. Duties to Notify and Assist The Veteran was notified of the elements of service connection and of his and VA's respective responsibilities for obtaining relevant records and other evidence in support of his claim. See August 2009 and November 2009 Correspondence. The duty to notify is satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). VA's duty to assist under the VCAA includes helping claimants to obtain service treatment records (STRs) and other pertinent records, to include private medical records (PMRs). See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The claims file contains the Veteran's STRs, PMRs, and VAMRs. The Veteran has indicated that his reported in-service back and right thumb injuries required several months of treatment during active duty. June 1997 Statement (explaining that the 1975 tank accident caused the Veteran to "[fa]ll inside of tank" and to be "treated [for back pain] at a post clinic for approximately 5 months" and for thumb problems "at Army Hospital for about 4 months"). He did not indicate that he was hospitalized in connection with his reported in-service back and/or right thumb condition. Although the Veteran is competent to report treatment for a given medical problem, his assertion that he required extensive-i.e., several months of-medical treatment in relation to his reported in-service injuries lack credibility. The STRs do not mention any extensive treatment for a back and/or thumb condition in service and the Veteran's separation examination, to include his Report of Medical History, does not indicate that he underwent any such treatment during active duty. May 1979 Reports of Medical Examination and History. The STRs appear to be complete: the claims file contains the Veteran's entrance and separation examinations as well as STRs for the duration of the Veteran's period of active duty. May 1975 and May 1979 Reports of Medical History and Examination. Thus, the Board finds that the Veteran's reports of extensive medical treatment following his claimed in-service injuries are improbable and, consequently, remand to obtain additional STRs is not necessary. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (finding that remands which would impose additional burdens on VA with no benefit flowing to the Veteran are to be avoided); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to the law does not require an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran). The duty to obtain relevant records is satisfied. See 38 C.F.R. § 3.159(c). VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The VA examination and/or opinion must be adequate to decide the claim. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). VA examinations were performed in December 2013 and addendum opinions were issued in October 2014. The examination reports and addendum opinions are sufficient to decide the Veteran's service-connection claims. The examiners reviewed the electronic claims file, performed an in-person examination, and described the etiology of the Veteran's disabilities in sufficient detail to enable the Board to make a fully informed decision. See Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion"). The medical evidence received after the October 2014 addendum opinions does not indicate any significant or material change in the Veteran's disability picture in relation to the disabilities on appeal. The Veteran has not received a new diagnosis related to his back and/or thumb disabilities and there is no new evidence relevant to the etiology of the disabilities on appeal. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (holding that a new VA examination is not required simply because of the passage of time since an otherwise adequate examination was conducted). VA has satisfied its duties to notify and assist and the Veteran has had ample opportunity to participate in the development of his claim. B. Compliance with the Board's Prior Remand Directives The Board has remanded this appeal for additional development on four separate occasions. See January 2012, February 2013, September 2013, and September 2014 Board Decisions. Pursuant to the Board's remand directives, the RO obtained the Veteran's updated VA medical records, obtained addendum opinions from a VA audiologist and a VA physician, and readjudicated the claims on appeal. See September 2015 Supplemental Statement of the Case. The Board finds substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West., 13 Vet. App. 141, 147 (1999). C. Compliance with Hearing Officer's Duties As noted above, the Veteran testified at a hearing before the undersigned in July 2011. Under 38 C.F.R. § 3.103(c)(2) (2015), the hearing officer must fully explain the issues on appeal and suggest the submission of evidence that the claimant may have overlooked and that would be of advantage to the claimant's position. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that the hearing officer has two duties under § 3.103(c)(2). First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Id. at 496. Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Id. at 496-97. At the hearing, the Veteran had an opportunity to provide testimony in support of his claims, facilitated by questioning from the undersigned and his representative. The undersigned elicited testimony from the Veteran regarding the etiology of the disabilities on appeal. The Veteran did not raise any new issues at the hearing, and there is no indication that any outstanding evidence might exist that would provide additional support for the Veteran's claims. Moreover, the Board undertook additional development after the hearing was conducted, including obtaining additional VA records, and arranging for VA examinations to determine the etiology of the Veteran's claimed disabilities. See id. at 498-99 (finding that any deficiencies in discharging the hearing officer's duties under § 3.103(c)(2) were rendered harmless by otherwise developing the record). Given this development, in addition to the Veteran's testimony at the hearing and the evidence in the claims file, the "clarity and completeness of the hearing record [is] intact: and there is no prejudicial error concerning the hearing officer's duties under § 3.103(c)(2). See Bryant, 23 Vet. App. at 498 (holding that the rule of prejudicial error applies to compliance with the hearing officer's duties under § 3.103(c)(2)); see also Sanders, 556 U.S. at 407, 410. Merits of the Claims Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2015). Entitlement to service connection may be established on a direct basis with evidence showing (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).). 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be established on a presumptive basis for the chronic diseases listed in 38 C.F.R. § 3.309(a). The presumption for chronic diseases relaxes the evidentiary requirements for establishing entitlement to service connection. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012) (holding that "[t]he clear purpose of [subsection 3.303(b)] is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases," and only applies to the chronic diseases set forth in § 3.309(a)). Specifically, § 3.303(b) provides that 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 causes unrelated to service ("intercurrent causes"). If the evidence is not sufficient to show that the disease was chronic at the time of service, then the claim may be established with evidence of a continuity of symptoms after service, which is a distinct and lesser evidentiary burden than the nexus element of the three-part test under Shedden. Walker, 708 F.3d at 1338; C.F.R. § 3.303(b). Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during a] presumptive period." Id. (observing that a claim for a chronic disease "benefits from presumptive service connection . . . or service connection via continuity of symptomatology"). The Veteran has been diagnosed as having tinnitus as well as degenerative joint disease of the spine and right hand. Because organic diseases of the nervous system, to include tinnitus, and arthritis are defined as chronic in section 3.309(a), the provisions of subsection 3.303(b) for chronic diseases apply and the claims may be established with evidence of chronicity in service or a continuity of symptomatology after service. See Walker, 708 F.3d at 1338-1339. Where a claimant served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, service connection may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307; 3.309(a). This presumption may be rebutted by affirmative evidence to the contrary. 38 C.F.R. § 3.307(d). Tinnitus The Veteran alleges that his current tinnitus was caused by in-service noise exposure. The claim is granted. The Veteran has in-service noise exposure. He served as a cannon crewman and trained as a marksman during active duty in the U.S. Army. See Form DD 214. His military duties required regular exposure to artillery fire without hearing protection. August 2008 Statement; October 2009 VA Examination Report (noting in-service noise exposure from "artillery, weapons, aircraft, heavy equipment, explosives and diesel engines); July 2011 Hearing Transcript (testifying that the Veteran experienced "a lot of noise exposure" in service-he operated "all kind of Arms firing equipment" without hearing protection-and experienced ear bleeds in service). In an April 2011 statement, a fellow service member reported that the Veteran was removed from the gun line in July 1975 due to hearing problems. See also July 2011 Hearing Transcript (testifying that the Veteran was removed from his regular duties as a cannon crewman and ordered to work in the kitchen due to hearing problems). In May 1977, the Veteran was treated for earache in his right ear due to "receiving blow to ear while boxing." He was assessed as having otitis external and treated with Cortisporin. In February 1979, he presented with left ear ache. The audiometer readings documented on the Veteran's separation examination are incorrect and so do not provide an accurate assessment of his hearing at service separation in May 1979. See Report of Medical Examination ("Suspect error in audio."); December 2013 VA Medical Examination (determining that the "supposed error in audio" on the Veteran's separation examination "appears to be a reasonable assumption"). The Veteran's self-reported medical history is similarly inconclusive: he both asserts and denies having hearing problems at separation. May 1979 Report of Medical History. VA medical records establish that the Veteran has been diagnosed as having tinnitus and has received treatment for this condition for several years. January 2010 VAMRs. In February 1986 the Veteran reported hearing problems and was treated for ear ache. More recently, in February 2008 the Veteran underwent audiological testing, but could not complete the testing because the ringing in his ears became so pronounced as to become painful. The Veteran continued to report ringing in his ears and seek medical treatment for his tinnitus from 2008 onward. June 2008 through September 2008 VAMRs; May VAMRs (evaluating the Veteran for hearing aids due to hearing loss and tinnitus). In October 2009, a VA examiner noted that the Veteran reported having earache in 1977 and was subsequently treated for external otitis. Audiological test results were inconclusive and the examiner did not opine as to the etiology of the Veteran's tinnitus. In February 2012, a VA audiologist noted that the Veteran's tinnitus-a constant high pitched sound-reportedly manifested around 1975 and worsen with chewing. The examiner opined that the Veteran's current tinnitus did not relate to the Veteran's hearing loss because there were no threshold shifts noted during his military career. In May 2013, a VA audiologist noted that the Veteran's tinnitus reportedly first manifested in 1976 after he was engaged in artillery practice without the benefit of hearing protection. The examiner also opined that the Veteran's current tinnitus did not relate to his hearing loss because there were no threshold shifts noted during his military career. In December 2013, another VA audiologist found that "the veteran's current tinnitus is less likely as not due to noise exposure in service." She noted the Veteran's reports of specific instances of in-service noise exposure and of a "continuation of difficulties with tinnitus since time in service." However, she also noted "a lack of undisputed objective evidence of permanent noise-induced damage to hearing over time in service based on frequency specific audiological testing during time in service." In October 2014, another VA audiologist found that the Veteran's current hearing loss levels could not be accurately measured and opined that "[d]ue to the unknown status of the veteran's hearing at this time, an opinion regarding tinnitus and military noise exposure cannot be provided." The audiologist based her opinion on a review of the Veteran's claims file. The Veteran insists that his tinnitus began in service. October 2009, February 2012 and May 2013 VA Examination Reports; see also Statements dated April 2004, July 2011, and December 2011. During the July 2011 hearing, the Veteran testified that he experienced "ringing in his ears in service" and that he was denied promotion due to his inability to "hear the code to pass the ammo and stuff like that." See contra June 2008 VAMRs (reporting that the Veteran's tinnitus first manifested in 1994 and that the Veteran had "a lot of noise exposure in the military" as well as "some noise exposure as a civilian working in a factory and on a truck loading dock"); July through September 2008 VAMRs (reporting that the Veteran's tinnitus manifested four years prior (i.e., 2004) and is of an unknown etiology). Similarly, statements by friends and family suggest that the Veteran's tinnitus has been ongoing for several years. February 2011 Statement by Employer/Supervisor (reporting that the Veteran requires repeated instructions due to the ringing in his ears); June 2011 Statement by Grandson (reporting that the Veteran's hearing problems have been "going on over a period of years"); July 2011 Statement by Granddaughter (reporting that the Veteran has had seriously bad hearing problems "over the years"). The VA examination reports are inconclusive. The October 2009 and February 2012 VA examiner failed to opine as to whether the Veteran's tinnitus related directly to service. The December 2013 VA examiner's reasoning is inadequate it that it relies on the absence of evidence to outweight the Veteran's competent statements regarding the history of his tinnitus. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (finding that the VA examination was inadequate where the examiner did not comment on reports of in-service injury and relied on the absence of evidence in the STRs to provide a negative opinion). Finally, the October 2014 VA audiologist found that "an opinion regarding tinnitus and military noise exposure cannot be provided" because the Veteran's hearing levels could not be accurately measured at the time of the examinatin. Thus, the February 2012, May 2013, December 2013, and October 2014 VA examination reports lack significant probative value and the examiners' opinions are outweighed by the Veteran's statements that his tinnitus manifested in service and has been ongoing since service separation. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that lay statements regarding symptoms that are experienced on a first-hand basis constitute competent evidence); Jandreau v. Nicholson, 492 F. 3d 1372, 1377 & n4 (Fed. Cir. 2007). Entitlement to service connection for tinnitus is granted. See 38 C.F.R. §§ 3.102; 4.3 (2014); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Back The Veteran alleges that his current low back disability relates to service. He states that he injured his back in service when the tank in which he was travelling ran off the road and fell twenty feet, causing him to be flung around the tank passenger compartment. December 2010 Substantive Appeal (VA Form 9); July 2011 Hearing Transcript. The Veteran's STRs are negative for any ongoing back problems in service, to include arthritis. In May 1979, the Veteran was treated for acute low back strain. His STRs document minimal lumbosacral tenderness, full range of spinal motion, and a negative straight leg raise test. Three days later, the Veteran reported for a follow-up visit and was found to be "completely normal at this time." May 1979 STRs. His separation examination-which was conducted in the same month-was negative for any back problems and the Veteran denied having recurrent back pain. May 1979 Reports of Medical Examination and History. Post-service treatment records indicate that the Veteran was first treated for back problems several years after service separation. In September 1986, the Veteran complained of back pain after lifting heavy boxes at work and reported that he had had back pain for the previous three years. September 1986 VA Medical Certificate (Form 10-10). X-rays taken at the time revealed slight narrowing of the L5-S1 disc space; however, they also showed that the height of the lumbar vertebra and of the remaining intervertebral spaces were fairly well preserved. Spina bifida was noted at L5. Subsequent VA treatment records document treatment for intermittent back problems from the late 1990s onward. In August 1997, the Veteran reported having low back pain, but denied any trauma to his back. His range of spinal motion was within normal limits and X-rays of the low back were unremarkable. August 1997 VAMRs (finding that the vertebral bodies height and alignment are normal, intervertebral disc spaces are well maintained, no fractures or dislocation, and no significant degenerative changes). He was diagnosed as having chronic low back pain due to muscle strain. September 1997 VAMRs. In February 2001, the Veteran reported that his health was "excellent" and that "[h]e has no problems with heavy lifting." February 2001 VAMRs. VA treatment records also document several back injuries that required medical treatment. In April 2003, the Veteran reported the recent onset of left-sided, low back pain that manifested after he did some heavy lifting as part of his civilian job duties. The Veteran denied a history of similar back pain. In February 2005, a VA nurse noted that the Veteran experienced back pain after he fell about five feet onto his low back and right side while at work. The following month (March 2005), the Veteran required urgent care for back pain. VA medical records note recent evidence of spina bifida as well as moderate tenderness over the low back and a negative straight leg test. The evaluating VA physician noted that the Veteran's "main objective is to get a work excuse especially since he asked for one" on a recent previous visit. In June 2009, the Veteran was diagnosed as having osteoarthritis with low back pain, which is controlled with prescription medication. June 2009 VAMRs. VA medical records from August 2010 note a history of low back pain as well as treatment for another back injury. The Veteran reported "that he was lifting a bed and felt a pop in his back." He also reported that his low back pain reduced after he sat for an hour, but that his symptoms returned the morning of the appointment. The Veteran demonstrated a full range of spinal motion on physical examination and was prescribed pain medication and advised to avoid heavy lifting. More recently, in February 2012 a private physician observed that the Veteran had a normal gait, but was unable to touch his toes due to pain. The physician diagnosed the Veteran as having low back pain. In the same month (February 2012), a VA examiner noted that the Veteran had been diagnosed as having back strain/sprain, degenerative disc disease, and spina bifida occulta. The examiner opined that the Veteran's current back problems do not relate to service and are more likely due to genetic factors like aging, body habitus, and cumulative life actives. The examiner noted the Veteran's reports that he injured his back in January 1976 when he was involved in a tank accident while stationed in Germany and that he has had occasional low back pain and stiffness since military service. The examiner also noted that the Veteran was treated for acute low back pain in May 1979 after he bent over and picked up an object and that the condition improved with medication to the extent that the Veteran denied occasional or recurrent back problems at service separation. The examiner observed that the Veteran experienced several falls without serious injury in the 1990s, that his lumbar spine appeared normal on X-rays taken in 1997 and 2005, and that X-rays taken in 2009 showed mild degenerative disc disease at L5/S1. Diagnostic tests taken as part of the VA examination revealed narrowing of the disk space at L5-S1 and spina bifida occulta at L5, but no sign of fracture or dislocation. The Veteran continued to report back pain throughout 2013 that was exacerbated by physical activity and to seek treatment for his symptoms. In July 2013, he presented with bilateral lower back pain without radiation or numbness/tingling of the extremities. VA treatment records note that the Veteran "[w]orks at the VA and bends over frequently." July 2013 VAMRs (reporting that the Veteran "works in housekeeping and is noted to do a lot of pushing, bending, and lifting daily" and explaining that the Veteran's occupation "will lead to more frequent exacerbations of [back] pain"); see contra September 2013 VAMRs (reporting a history of low back pain since military service and that the Veteran "did not work full time after that or do any jobs that caused strain to his back."). In December 2013, another VA examiner opined that it is less likely than not that the Veteran's current low back disorder relates to military service, to include as due to the Veteran's reported in-service tank accident. The examiner diagnosed the Veteran as having lumbosacral strain and concluded that there is "inadequate documentation of ongoing treatment and/or disability to create a continuum or chronicity with his in-service event." VA medical records from May 2014 show a diagnosis of chronic low back pain and no recent trauma or injury. In August 2014, diagnostic tests confirmed that the Veteran had mild narrowing at L3-4 with prominent bilateral foraminal stenosis and partial sacralization at L5, but no acute intervertebral disc abnormality. See also May 2015 VAMRs (finding that the Veteran has osteoarthritis of the lumbar spine) In October 2014, the same VA examiner provided an addendum opinion in which she restated that the Veteran's low back disability was less likely than not incurred in or caused by service, to include the in-service tank accident. The examiner found that the Veteran had a "singular episode of documented low back pain during military service" and some mild upper back pain in 1976/77 that related to costochondritis and chest wall pain. She noted that the Veteran's May 1979 back pain was "mild [in] nature"-straight leg testing was negative-and did not require additional treatment to resolve. Based on a review of the Veteran's STRs and post-service medical treatment, the examiner concluded that the negative May 1979 straight leg raise test suggests "it [is] less likely than not that the veteran's . . . degenerative disc disease at L5-S1 was present or the cause of his back pain in 1979." She also concluded that the "very mild nature of the back condition noted in early May of 1979 . . . do[es] not support linkage of the event in military service to any subsequent back pain." Thus, the VA examiner opined that the Veteran's May 1979 back complaints resolved without evidence of sequelae and that there is no "linkage of the event in military service to any subsequent back pain." More generally, the VA examiner opined that the Veteran's STRs and post-service medical treatment records suggest that any low back pain that occurred in service resolved prior to separation. She noted that the Veteran denied having back problems on separation and that his separation examination was negative for any back problems. She also noted that the Veteran's self-reported medical history (provided in 1986) suggests that his back pain onset no earlier than 1983 or "well after the veteran left military service" in May 1979. In addition, the examiner found that the Veteran's in-service upper back pain "would not have had any influence on the lumbar spine" due to its localized nature. Thus, the examiner found that that the "objective evidence does not support the veteran's contention" that his current back disability developed during military service. VA medical records dated after the October 2014 VA opinion, document treatment for chronic back pain, to include a refitting of a prescription back brace, with periods of exacerbated symptoms. November 2015 VAMRs; December 2015 and January 2016 VAMRs. In June 2015, the Veteran reported worsening back pain over the previous few days and reported "that certain movements that he may have done at work may have exacerbated the pain." In August 2015, the Veteran reported worse back pain after he was involved in a physical altercation. The Veteran is competent to report that he was involved in an in-service tank accident. December 2010 Statement, February 2012 VAMRs; see also 38 C.F.R. 3.159(a) (2015), Layno v. Brown, 6 Vet. App. 465, 470-71 (1994), Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). Although his statements regarding the time and location of the tank accident are contradictory, the Veteran has consistently stated that he was involved in a tank accident while he was on active duty. September 1994 Claim (stating that the Veteran injured his back in 1975 when he was stationed at Fort Sill, Oklahoma and/or at Fort Carson, Colorado); June 1997 Statement (stating that the Veteran injured his back in 1975 when he was stationed at Fort Sill); May 2010 VAMRs (reporting that when the Veteran was stationed in Germany the tank in which he was riding ran off the road and that he was subsequently thrown around the tank compartment); July 2011 Hearing Transcript (testifying that the Veteran injured his back in a tank accident while stationed in Germany); February 2012 VA Examination Report (reporting that the Veteran injured his back in January 1976 when he was involved in a tank accident while stationed in Germany); see also December 2011 Statement by a Service Member (reporting that the Veteran was involved in a tank accident (in Germany) during military service). Giving the Veteran the benefit of the doubt, the Board finds that the Veteran injured his back in a tank accident while on active duty. As an initial matter, the STRs suggest that any back injury that resulted from the Veteran's reported in-service tank accident was minor and that it resolved prior to service separation. Although not determinative, the fact that the Veteran regularly sought medical treatment for even relatively minor medical conditions (e.g., a cold) throughout service indicates that he was willing and able to seek medical treatment for the likes of a low back pain. See e.g., January 1978 STRs (treating the Veteran for a boil in groin area); February 1978 STRs (treating the Veteran's cold symptoms); May 1978 (treating the Veteran's post circumcision pain). In this respect, the absence of any reports of or treatment for low back pain prior to May 1979 constitutes persuasive evidence that the tank accident did not result in significant back pain-pain that required medical treatment-and that any back pain caused by the accident promptly resolved. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (holding that silence in the STRs can constitute "contradictory" evidence weighing against the credibility of a claimant's testimony if the STRs are complete "in relevant part" and there is competent evidence that the claimed "injury, disease, or related symptoms would ordinarily have been recorded had they occurred"). In addition, the Veteran completed at least three years of military service-to include rigorous physical training-after the tank accident without apparent difficulty or complaint of back pain. Thus, the STRs weigh against finding that the Veteran's reported back injury in 1975/1976 resulted in permanent injury and/or chronic back pain and outweigh the Veteran's recollection to the contrary. See June 1997 Statement (reporting that the Veteran "was treated at a post clinic for approximately 5 months); see also Curry v. Brown, 7 Vet. App. 59 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant). Although the Veteran is also competent to report that he received treatment for a back injury in service, his assertions that his low back symptoms have persisted since service are outweighed by the contemporaneous medical evidence. The STRs do not document any in-service back problems until May 1979 when the Veteran was treated for a back strain and suggest that this injury resolved prior to service separation. See May 1979 STRs (noting no back problems three days after the Veteran was treated for an acute low back strain in May 1979-the Veteran reported that he was completely healthy). In addition, the Veteran's separation examination was negative for any low back problems, to include spinal arthritis, and he denied having recurrent back pain upon separation. May 1979 Reports of Medical Examination and History. The Veteran's separation examination and report of medical history constitute probative evidence that he did not experience chronic back pain during service. The separation examination was performed to ascertain the Veteran's state of physical health and is equivalent to statements of diagnosis and/or treatment. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that recourse to the Federal Rules of Evidence may be appropriate to assist in the articulation of the Board's decision); see also LILLY'S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (observing that statements made to physicians for purposes of diagnosis and/or treatment are often exempted from the general prohibition of hearsay because the declarant has a strong motive to tell the truth in order to receive proper medical care). Similarly, the May 1979 Report of Medical History constitutes a complete assessment of the Veteran's medical problems at separation from service. See AZ v. Shinseki, 731 F. 3d 1303, 1315 (Fed. Cir. 2013) (finding that the absence of an entry in a record may be considered evidence that a fact did not occur if the fact would have been recorded if present). Thus, the Veteran's Reports of Medical Examination and History weigh against a continuity of symptomatology between service and the Veteran's current low back disabilities. Post-service medical records also suggest that the Veteran's back problems did not manifest for several years after service. During treatment at a VA facility in September 1986, the Veteran reported that his back pain began three years prior or over four years after service separation. See September 1986 VA Medical Certificate (Form 10-10). Moreover, in February 2001 the Veteran reported being in "excellent" health and having "no problems with heavy lifting." February 2001 VAMRs. Thus, by his own account the Veteran's chronic back pain did not manifest in or within a year of service and likely manifested many years after service. Similarly, X-ray evidence shows that the Veteran's spinal arthritis manifest approximately three decades after service separation. See August 1997 VAMRs (noting that X-rays of the low back were unremarkable and diagnosing the Veteran as having back strain); June 2009 VAMRs (diagnosing osteoarthritis with low back pain); February 2012 VA Examination Report (finding that spinal arthritis was first revealed on X-rays taken in 2009 first revealed spinal arthritis). Further, although the Veteran is competent to report that he injured his back due to an in-service tank accident, he is not competent to opine as to whether his current low back disability relates to service. See Washington, 19 Vet. App. at 368 (holding that the claimant was competent to testify as to factual matters such as experiencing pain in his right hip). Whether the Veteran's low back disability was caused or aggravated by his in-service tank accident is a medically complex determination that cannot be made based on lay observation alone. Jandreau, 492 F. 3d at 1376-77 & n4; Barr, 21 Vet. App. at 309. Since the Veteran lacks medical training and experience, his assertions that his low back disability was caused by his in-service tank accident is not competent evidence. See Layno, 6 Vet. App. at 470-71. In contrast, the December 2013 VA examination report and October 2014 addendum opinion constitute highly probative evidence that weighs against entitlement to service connection for a low back disability. The examination was conducted by a VA doctor who reviewed the Veteran's claims file and pertinent medical history, examined the Veteran, and provided a clear rationale for her opinion that the Veteran's current low back disability does not relate to service. Moreover, the examiner's opinion is consistent with findings documented in VA treatment records and with previous VA examination findings. See February 2012 VA Examination Report. Thus, the Veteran's statements are outweighed by the VA examiner's medical opinion, which was rendered by a medical professional and supported by objective medical findings, and finds that the Veteran's low back disability was not caused or aggravated by active duty service. See October 2014 VA Opinion. The fact that over 5 years elapsed between service separation, in May 1979, and treatment for low back pain, in September 1986, further weighs against a relationship to service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that, in assessing whether a claimed disorder was incurred in active service, a proper consideration for the trier of fact is the amount of time that has elapsed since military service). Moreover, the Veteran only reported back pain after having worked for several years in physically demanding civilian occupations that required heavy lifting. September 1986 VA Medical Certificate (Form 10-10) (reporting back pain due to lifting boxes); February 2001 VAMRs (reporting that the Veteran loaded and unloaded truck for a living between about 1981 and 1985, then worked as a custodian for a year, and then worked as a forklift operator for two years); September 2002 and March 2005 VAMRs (reporting that the Veteran worked as a dock worker for a trucking company between approximately 1981 and 1995); See generally February 2012 VA Examination Report (noting a history of strenuous physical activity and workplace falls). Thus, the probative evidence of record weighs against a relationship between the Veteran's low back disability and military service. In summary, the fact that the STRs do not document ongoing back pain in service and that post-service medical records do not document low back pain for several years after service separation-and after several years of working physically demanding civilian jobs-weighs against finding that the Veteran's current low back disability was caused or aggravated by service. The preponderance of the evidence is against the Veteran's claim. The benefit-of-the-doubt rule does not apply and service connection for a back disability is denied. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55. Right Thumb The Veteran alleges that his current right thumb disability relates to an in-service injury. February 2005 Notice of Disagreement (NOD); December 2010 Substantive Appeal; July 2011 Hearing Transcript. The STRs show that in March 1979 the Veteran was assessed as having a possible infection of the right thumb (on the lateral aspect over the proximal interphalangeal joint with mild edema and mild ecchymosis). The Veteran reported that he injured his thumb four days prior. X-rays taken at the time were negative for any abnormality. On service separation, the Veteran denied any problems with his joints and his separation examination did not reveal any problems with the right thumb or hand. May 1979 Reports of Medical Examination and History. The Veteran's STRs do not document any reports of or treatment for arthritis in service. Post-service medical records document a history of right thumb symptoms dating back to 1996. In February 1996, the Veteran reported problems with his right thumb. X-rays of the thumb showed "no significant bone or joint abnormality . . . The examination is within normal limits." In June 1997, the Veteran again reported numbness in the area of the right thumb. In July 2004, the Veteran reported some right hand/thumb pain and was prescribed naproxen to relieve his symptoms. VA medical records indicate that the Veteran lacerated his right hand after punching through a window. The Veteran complained of chronic recurrent right hand/thumb pain, weakness, and loss of grip; however, he denied any other trauma to the right hand and was able to move his right hand and fingers on examination. July 2004 VAMRs. He had swelling in the right thumb joint, but no arthralgias, myalgias, or weakness. In February 2012, a private physician examined the Veteran and noted early soft tissue swelling over the joints in his hands consistent with arthritic changes. In the same month (February 2012), a VA examiner opined that the Veteran's right thumb disability was less likely than not related to service. He noted that the Veteran's thumb was reportedly injured in service when it was closed in a tank door, resulting in a "sustain[ed] abrasion to radial side of distal interphalangeae joint of right thumb." However, he also noted that X-rays of the right hand taken at the time were normal and that the Veteran's right hand was normal on separation. May 1979 Reports of Medical Examination and History. The examiner observed that the Veteran had anterior hypertrophic spondylosis in his neck at C6. The Veteran reported having had intermittent pain in his right thumb since 1980 and that he experienced a tingling sensation in his right thumb as well as in the fingertips of both hands. The examiner concluded that the fact that the February 2012 X-rays revealed early degenerative changes of the distal interphalangeal joint spaces on the Veteran's right hand (osteoarthritis)-not just the right thumb-suggested that the Veteran's right thumb symptoms likely relate to genetic factors, the aging process, and cumulative life activities rather than to an in-service thumb injury. April 2012 VA medical records indicate that the Veteran had had joint pain since July 2004 and osteoarthrosis since December 2006. In November 2012, the Veteran noted that the problems with his right thumb were persisting and that they had spread to a larger portion of his right hand. See also July 2013 VAMRs (noting pain in the right first metacarpophalangeal joint). In October 2013, the Veteran reported having experienced numbness in his right thumb for "many years" and a VA physician informed the Veteran that his thumb symptoms were nerve-related rather than musculoskeletal in nature. X-rays from November 2013 revealed mild degenerative changes of the interphalangeal joint of the right thumb, but no fractures or suspicious bony lesions and normal alignment. In December 2013, another VA examiner opined that it is less likely than not that the Veterans current right thumb symptoms relate to his military service. The examiner noted that the Veteran reportedly injured his thumb in service when a tank hatch fell on it and had been diagnosed as having a right thumb laceration. The examiner concluded that there was "inadequate documentation and clinical findings to relate his [the Veteran's] right thumb condition to his military service." She also found that the Veteran's description of his current symptoms-numbness of the lateral half of the right thumb that extends distally from the level of the first metacarpal phalangeal joint-is "totally inconsistent with the level of his laceration" in service, "which was the inter-phalangeal joint." In February 2014, the Veteran reported that he had experienced chronic right thumb pain and numbness for the last ten to fifteen years. February 2014 VAMRs. In October 2014, the same VA examiner opined that "[i]t is less likely than not that the veterans current right thumb symptoms . . . are related to his military service or the injury sustained to his right thumb in 1979." She explained that the 1979 injury "was a skin laceration with possible infection which was on the distal joint of the thumb." Based on the nature of the Veteran's injury, the examiner found that "the veteran's reported numbness along the entire length of the thumb from the MCP to the end of the thumb does not correspond to any residual of the prior laceration of his thumb as it is not supported by the well-defined anatomy of the nerves." Thus, she concluded that the Veteran's 2004 right-hand symptoms "did not correspond to any potential sequelae of a laceration or infection of the skin on the distal thumb." The examiner added that the Veteran's STRs establish that his right hand symptoms "were clearly not present when he left the military" and, subsequently, that the Veteran's "right thumb injury in 1979 was a life event" that resolved within ongoing symptoms. Further, the examiner noted that X-ray evidence for the 1990s shows "no evidence of arthritis of the thumb." Although the Veteran is competent to report that he injured his right thumb in service, his statements regarding the nature of the in-service thumb injury lack credibility. 38 C.F.R. 3.159(a); Layno, 6 Vet. App. at 469; Washington, 19 Vet. App. at 368. Initially, the Veteran reported that he injured his right thumb in 1978 when he was stationed at Fort Carson and underwent four months of treatment. September 1994 Claim; June 1997 Statement; February 2005 NOD (suggesting that the Veteran injured his right thumb in December 1978). However, in July 2011 the Veteran testified that he injured his thumb in the same 1975 tank accident that reportedly resulted in a back injury. The Veteran explained that the impact of the tank running off the road caused his "thumb . . [to] hit the wall." July 2011 Hearing Transcript. During the February 2012 VA examination the Veteran reported that his right thumb was injured when a tank door closed on his right hand. Thus, the Veteran's statements regarding how he injured his right thumb in service are contradictory and, to the extent that they suggest that he injured his thumb prior to May 1979 (when the STRs document treatment for a right thumb infection), lack probative value. The contemporaneous medical evidence weighs against finding that the Veteran's current right thumb disability relates to service. The STRs show that the Veteran's in-service thumb infection resolved prior to service separation. May 1979 Report of Medical Examination (finding no abnormality associated with the Veteran's right thumb); May 1979 Report of Medical History (denying any problems of the joints, to include the right thumb). They also show that the Veteran did not have arthritis in service, see March 1979 X-rays, or within a year of service separation. Thus, the contemporaneous medical evidence suggests that any problems the Veteran had with his right thumb in service resolved prior to separation and did not result in any continuous symptoms that suggest his current right thumb problems related to service. See Rucker, 10 Vet. App. at 73; LILLY'S, 2nd Ed., pp. 245-46; AZ, 731 F. 3d at 1315. Post-service medical evidence confirms that the Veteran's current right thumb disability is not connected to service. VA medical records do not document complaints of right thumb symptoms or evidence of arthritis for well over a decade after service separation. In fact, in February 2014 the Veteran informed his VA physician that his chronic right thumb pain did not manifest until around 1990. February 2014 VAMRs (reporting right thumb pain and numbness for ten to fifteen years). In this respect, the medical evidence-to include the Veteran's self-reports of medical history-does not establish a continuity of symptomatology that links the Veteran's in-service right thumb injury with his current disability. See February 1996 and June 1997 VAMRs. Further, the Veteran is not competent to opine as to whether his current right thumb disability relates to service. Whether the Veteran's right thumb disability was caused or aggravated by service, to include an in-service right thumb infection, is a medically complex determination that cannot be made based on lay observation alone. Jandreau, 492 F. 3d at 1376-77 & n4; Barr, 21 Vet. App. at 309. Since the Veteran lacks medical training and experience, his assertions that his right thumb disability was caused by service is not competent evidence. See Layno, 6 Vet. App. at 470-71. In contrast, the December 2013 VA examination report and October 2014 addendum opinion constitute highly probative evidence that weighs against entitlement to service connection for a right thumb disability. The examination was conducted by a VA doctor who reviewed the Veteran's claims file and pertinent medical history, examined the Veteran, and provided a clear rationale for her opinion that the Veteran's current right thumb disability does not relate to service. The examiner's opinion is consistent with the STRs and with VA medical findings that show no right thumb symptoms or evidence of arthritis for well over a decade after service separation. See February 2012 VA Examination Report. Thus, the Veteran's assertions that his right thumb disability relates to service are outweighed by the VA examiner's medical opinion, which was rendered by a medical professional and supported by objective medical findings, and finds that the Veteran's right thumb disability was not caused or aggravated by active duty service. See October 2014 VA Opinion. The fact that over 18 years elapsed between service separation, in May 1979, and the earliest mention of right thumb pain, in June 1997, further weighs against a relationship to service. See Maxson, 230 F.3d at 1333. Moreover, the Veteran only reported having right thumb problems after many years of performing physical demanding work as a civilian employee, to include loading boxes onto trucks and custodial work that involved a lot of daily pushing, bending, and lifting. September 1986 VA Medical Certificate; February 2001 VAMRs; September 2002 VAMRs; March 2005 VAMRs; July 2013 VAMRs. Thus, the probative evidence of record weighs against a relationship between the Veteran's current right thumb disability and military service. In summary, the Veteran's right thumb arthritis did not manifest in or within a year of service, his in-service right thumb injury did not result in symptoms that continuously manifested from service separation onward, and the medical evidence does not support a relationship-a nexus-between the Veteran's in-service injury and his current right thumb disability. The preponderance of the evidence weighs against the claim. The benefit of the doubt does not apply and service connection for a right thumb disability is denied. ORDER Service connection for tinnitus is granted. Service connection for a low back disability is denied. Service connection for a right thumb injury is denied. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs