Citation Nr: 1612632 Decision Date: 03/29/16 Archive Date: 04/07/16 DOCKET NO. 13-05 902 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for a heart disability, to include aortic valve disease, including as secondary to hypertension. 2. Entitlement to service connection for a back (spine) disability. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from October 1985 to April 1990, and from June 1992 to September 1993. He also had periods of reserve service. This case comes to the Board of Veterans' Appeals (Board) on appeal from May 2011 and October 2012 decisions by the RO in Milwaukee, Wisconsin. A videoconference hearing was held in July 2014 before the undersigned Veterans Law Judge (VLJ) of the Board, and a transcript of this hearing is of record. In its February 2015 decision, the Board reopened the previously denied claim of service connection for a heart disability, and remanded the appeals for service connection for disabilities of the heart and back for additional development. The case was subsequently returned to the Board. The record before the Board consists of the Veteran's paper electronic Virtual VA and VBMS claims files. FINDINGS OF FACT 1. A heart disability was not noted during the Veteran's 1984 military entrance examination. 2. The Veteran's congenital disease of a bicuspid aortic valve was not noted on entrance into service, but clearly and unmistakably preexisted service entrance. 3. There is an approximate balance of evidence for and against the claim as to whether the Veteran's current valvular heart disease with aortic valve replacement (AVR) is related to his military service. 4. There is an approximate balance of evidence for and against the claim as to whether the Veteran's current multi-level lumbar degenerative spine disease, upper thoracic left paravertebral myofascial strain, lumbosacral strain and degenerative arthritis of the thoracic and lumbosacral spine are related to his military service. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in his favor, the Veteran's valvular heart disease with subsequent AVR was incurred during active service. 38 U.S.C.A. §§ 1110, 1111, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2015); VAOPGCPREC 82-90. 2. Resolving all reasonable doubt in his favor, chronic multi-level lumbar degenerative spine disease, upper thoracic left paravertebral myofascial strain, lumbosacral strain and degenerative arthritis of the thoracic and lumbosacral spine were incurred in active service. 38 U.S.C.A. §§ 1110, 1111, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.303(b) (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the appellant pre-adjudication notice as to the back claim by a letter dated in August 2010, and as to the heart claim by a letter dated in August 2012. The appellant has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination). VA also fulfilled its duty to assist the Veteran by obtaining all relevant evidence in support of his claim, which is obtainable, and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran has submitted written statements and lay statements in support of his claim. VA has obtained service treatment records (STRs), VA and private medical records, assisted the appellant in obtaining evidence, afforded the appellant a physical examination, and obtained medical opinions as to the etiology of the current heart and back disabilities. All known and available records relevant to the issues on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. The AOJ attempted to obtain records from the Social Security Administration (SSA), but in March 2013, the SSA indicated that the Veteran's records are unavailable as they were destroyed. In an April 2013 memorandum, the AOJ made a formal finding that these records are unavailable, and that further attempts to obtain them would be futile. The Board further finds that the RO has substantially complied with its February 2015 remand orders. In this regard, the Board directed that the Agency of Original Jurisdiction (AOJ) arrange for VA medical examinations and opinions, and this was done. Therefore, the Board finds that no further development is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Board observes that the May 2015 VA heart examination report, though competent, credible, and probative, is not fully responsive to the questions posed in the Board's remand. However, the Board finds that proceeding with an adjudication of the Veteran's heart claim is not prejudicial to him in light of the Board's favorable decision as to this issue. The Board finds that the May 2015 VA back examination is adequate and probative for VA purposes because the examiner relied on sufficient facts and data, considered the Veteran's history of back injury during service, provided a rationale for the opinion rendered, and there is no reason to believe that the examiner did not reliably apply scientific principles to the facts and data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). At this time, the Board also notes that it is cognizant of the ruling in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. § 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. However, as discussed above, to the extent possible, VA has obtained the relevant evidence and information needed to adjudicate this appeal. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the July 2014 Board hearing. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Service connection is granted if it is shown the Veteran suffers from disability resulting from an injury sustained or a disease contracted in the line of duty during active military service, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.306. Other diseases initially diagnosed after service also may be service connected if the evidence, including that pertinent to service, shows the diseases were incurred in service. 38 C.F.R. § 3.303(d). The Veteran's DD Forms 214 reflect that he served on active duty in the U.S. Army from October 1985 to April 1990, and his primary military occupational specialty (MOS) was general construction equipment operator. He had another period of active duty from June 1992 to September 1993, with additional periods of reserve service. Under the law, active military service includes (1) active duty (AD), but also (2) any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or an injury incurred or aggravated in the line of duty, and (3) any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury, but not disease, incurred or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident that occurred during such training. 38 U.S.C.A. § 101(24)(B); 38 C.F.R. § 3.6(a). ACDUTRA includes full-time duty performed by members of the National Guard or Air National Guard of any state under sections 316, 502, 503, 504, or 505 of title 32 of the United States Code. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c)(3). ACDUTRA includes full-time duty performed for training purposes by members of the Reserves. 38 C.F.R. § 3.6(c) (2015). INACDUTRA is generally duty (other than full-time duty) prescribed for Reserves or duty performed by a member of the National Guard of any State (other than full-time duty). 38 U.S.C.A. § 101(23) (West 2014); 38 C.F.R. § 3.6(d) (2015). Annual training is an example of active duty for training, while weekend drills are inactive duty training. As a threshold matter, veteran status must be established as a condition of eligibility for service connection benefits. Bowers v. Shinseki, 26 Vet. App. 201, 206 (2013) (observing that it is "axiomatic that, to receive VA disability compensation benefits, a claimant must first establish veteran status"). To establish status as a Veteran based upon a period of ACDUTRA, a claimant must establish that he was disabled from disease or injury incurred or aggravated in the line of duty during that period of ACDUTRA. 38 C.F.R. § 3.1(a), (d); Harris v. West, 13 Vet. App. 509 (2000); Paulson v. Brown, 7 Vet. App. 466 (1995). The Board observes that the Veteran has not yet established Veteran status with regard to any periods of military service other than October 1985 to April 1990, and June 1992 to September 1993. The fact that a claimant has established status as a Veteran for other periods of service does not obviate the need to establish that he is also a Veteran for purposes of the period of ACDUTRA where the claim for benefits is based on that period of ACDUTRA. Mercado-Martinez v. West, 11 Vet. App. 415 (1998). Without the status as a Veteran, a claimant trying to establish service connection cannot use the many presumptions in the law that are available only to Veterans. For example, presumptive periods allowing for the presumed incurrence of a condition in service do not apply to ACDUTRA or INACDUTRA, and neither do the presumptions of soundness and aggravation. See Donnellan v. Shinseki, 24 Vet. App. 167, 171 (2010); Smith v. Shinseki, 24 Vet. App. 40 (2010); Biggins v. Derwinski, 1 Vet. App. 474 (1991). Certain diseases like arthritis and cardiovascular-renal disease are considered chronic, per se, and therefore will be presumed to have been incurred in service if manifested to a compensable degree (meaning to at least 10-percent disabling) within one year of separation from service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303 (2014); see also Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection may also be granted for disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). An increase in severity of a non-service-connected disorder that is proximately due to or the result of a service-connected disability, and not due to the natural progress of the non-service-connected condition, will be service connected. Aggravation will be established by determining the baseline level of severity of the non-service-connected condition and deducting that baseline level, as well as any increase due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). Supporting medical nexus evidence generally is needed to associate a claimed condition with a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may only be awarded to an applicant who has disability existing on the date of application, not for past disability. Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997)); but see McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). See also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Heart Disability The Veteran contends that he has a current heart disability that was either incurred in active service, or was caused or aggravated by his service-connected hypertension. In correspondence submitted to VA, he admitted that he had a congenital condition, specifically aortic valve disease, and asserted that this condition was exacerbated by service-connected hypertension above and beyond the level of normal disease progression. See his February 2012 statement. He reiterated this assertion in subsequent statements, and has recently contended that his current heart condition began in service. Service connection and a noncompensable rating were established for hypertension in an August 1990 rating decision, effective from April 24, 1990. It was noted that the Veteran's blood pressure readings had been elevated in the past but were currently normal. In an August 2003 rating decision, the RO granted a higher compensable rating for hypertension, effective from October 29, 2001, on the basis that medical records showed that he needed continuous medication for control of his hypertension as of that date. A veteran is presumed in sound condition except for defects noted when examined and accepted for service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). If a condition is not noted upon entrance into service, then to rebut the presumption of soundness at service entrance VA must show by clear and unmistakable evidence both that there was a pre-existing condition and that it was not aggravated during or by the Veteran's service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); VAOPGCPREC 3-2003 (July 16, 2003). To satisfy this second-prong requirement for rebutting the presumption of soundness, the government must show by clear and unmistakable evidence either that there was no increase in disability during service or that any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006). If a pre-existing disability is noted upon entry into service, then the Veteran cannot bring a claim for service connection for that disability, only a claim for service-connected aggravation of that disability. And in that case, 38 U.S.C.A. § 1153 applies and the burden falls on him, not VA to establish aggravation. Wagner, 370 F.3d at 1096. A pre-existing injury or disease will be considered to have been aggravated during service when there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Congenital or developmental defects are not considered "diseases or injuries" within the meaning of applicable legislation and, hence, do not constitute disabilities for VA compensation purposes. See 38 C.F.R. §§ 3.303(c), 4.9 (2015). A review of the evidence reflects that the Veteran has current heart conditions, and has been diagnosed with history of bicuspid aortic valve, status post aortic valve replacement (AVR) in 2001, and history of complete heart block after AVR, status post permanent pacemaker (PPM) implant. The May 2015 VA examiner diagnosed heart block, valvular heart disease, and heart valve replacement. Consequently, the determinative issue is whether or not the current heart disabilities are attributable to his military service or to a service-connected disability. The Veteran served on active duty from October 1985 to April 1990, and from June 1992 to September 1993. During the latter period, he was ordered to active duty under 10 U.S.C. §§ 672(D), 682, and had no foreign service. He also had additional periods of reserve service in the Army National Guard (ARNG) of Wisconsin from April 1990 to May 2002. He was found medically unfit for retention. Service treatment records dated from the Veteran's first period of active duty (1985 to 1990) reflect that on enlistment medical examination in October 1984, his heart and chest were listed as normal. A chest X-ray study was negative. His blood pressure was 144/82. In April 1986, his blood pressure was elevated. On examination, there was a 2/6 systolic ejection murmur in the left SB, with no clicks. The diagnosis was hypertension. Additional tests were planned. An April 1986 chest X-ray study showed no acute cardiopulmonary disease, with a prominent aortic [illegible], and a prominent ascending aorta. Another follow-up film was suggested if appropriate. A May 1986 service treatment record shows that the Veteran had high blood pressure, for which he was given medication. It was noted that a lordotic and oblique chest X-ray study in April 1986 showed a questionable large ascending aorta. Service treatment records dated in May and June 1986 reflect that the Veteran was taking Dyazide for high blood pressure. A July 1986 electrocardiogram (ECG) showed incomplete right bundle branch block and early repolarization of precordial leads. In June 1987 it was noted that he had stopped taking Dyazide. In September 1989, the Veteran presented with complaints of a sore throat and body aches. On examination, his heart had a regular rate and rhythm, and a 2/6 systolic ejection murmur, with no radiation. The diagnostic assessment was viral syndrome and benign ejection murmur. In a February 1990 report of medical history, the Veteran denied a history of chest pain or pressure, or heart trouble. He reported a history of high or low blood pressure. On separation medical examination in February 1990, the Veteran's heart and chest were normal. It was noted that a January 1990 chest X-ray study was normal. His blood pressure was 130/94. On VA examination in August 1990, with regard to his cardiovascular system, the Veteran reported that one time, during service, his blood pressure was checked and found to be slightly elevated. He was put on a diuretic, and when it was checked later, it was normal. He said that on discharge examination he was told that his blood pressure was borderline hypertension. On examination, the Veteran's blood pressure was 140/88 in the left arm, and on retake 20 minutes later, it was 132/86. In the right arm it was 138/90, and on retake 20 minutes later, it was 128/86. A cardiac examination showed no cardiomegaly, thrills, or murmurs, and his heart had a normal sinus rhythm. An August 1990 chest X-ray study was normal, and the heart and mediastinum appeared within normal limits. An August 1990 electrocardiogram showed normal sinus rhythm and incomplete right bundle branch. The examiner indicated that the Veteran had normal blood pressure. Service treatment records reflect that a July 1993 chest X-ray study was negative for active disease. A July 1993 report of medical history reflects that the Veteran reported a history of high or low blood pressure. He reported that he was treated for hypertension in 1986 in Germany during a two-week period. The reviewing examiner noted that he had borderline hypertension. On separation medical examination in July 1993, the Veteran's heart and spine were normal. His blood pressure was 139/96 sitting. The diagnosis was borderline hypertension. On periodic medical examination performed in December 1994, the Veteran's heart and chest were normal. His blood pressure was 154/104 sitting, and 136/102 recumbent. His spine was normal. An electrocardiogram showed left ventricular hypertrophy (LVH) by voltage, intraventricular conduction defect, and normal sinus rhythm. The examiner indicated that he had persistent hypertension (history of in the past), on no treatment as no current disability. He had an abnormal electrocardiogram (LVH - questionably secondary to prolonged hypertension). He was found qualified for retention. He was told to follow up with his local doctor for blood pressure control. A December 1994 report of medical history reflects that the Veteran gave a history of high or low blood pressure; the examiner noted that the Veteran had a history of hypertension in 1986, on diuretic for three weeks and was otherwise asymptomatic. A February 1995 service treatment record sick slip reflects that the Veteran complained of sunburn and exhaustion and was diagnosed with overexposure and exhaustion in unacclimatized soldier. On periodic medical examination performed in July 1998, the Veteran's heart, chest, and spine were normal. An electrocardiogram was within normal limits. His blood pressure was 130/90 sitting, 128/88 recumbent, and 120/80 standing. He was found qualified for retention. A July 1998 electrocardiogram showed sinus bradycardia but was otherwise normal. In a July 1998 report of medical history, the Veteran gave a history of high or low blood pressure. The reviewing examiner noted that the Veteran had two episodes of borderline high blood pressure on active duty but had no sequelae since. A July 1998 cardiovascular screening noted that an electrocardiogram was normal and the cardiovascular history and physical were normal. A March 2001 ARNG cardiovascular screening noted that an electrocardiogram was abnormal, and his blood pressure was 130/80. The examiner indicated that there were significant cardiovascular findings. On service medical examination in March 2001, the Veteran's heart was abnormal. He was noted to have a heart murmur. His blood pressure was 140/100 sitting, 140/84 recumbent and 130/80 standing. The examiner indicated that he had a new systolic murmur, and questionable aortic stenosis. An electrocardiogram showed irregular sinus bradycardia, probable aberrantly conducted supraventricular extrasystoles; summary borderline normal. In a March 2001 report of medical history, the Veteran gave a history of high or low blood pressure. The reviewing examiner noted that he had high blood pressure and saw a doctor for medication. He said the condition caused no problems. By a letter dated in August 2001, a private physician, W.W.Y., MD, stated that the Veteran had aortic stenosis and aortic aneurysm, and needed surgery in the near future to correct this problem. He said that a surgical valve would be placed in his heart which would solve the problem, and he had an excellent prognosis after the surgery. He had no duty limitations other than a limit of 20 pounds for lifting. By a letter dated in December 2001, a private physician, C.M.C., MD, stated that he treated the Veteran for a bicuspid aortic valve and associated ascending aortic aneurysm. In October 2001 the Veteran underwent aortic valve replacement (AVR) and Dacron graft replacement of the ascending aortic aneurysmal segment. The surgery went well, but his postoperative course was complicated by an episode of complete heart block for which he underwent permanent pacemaker implantation. He indicated that the Veteran's hypertension was well controlled at the present time on Toprol XL, and he needed to maintain anticoagulation with Coumadin on a long-term basis. In a January 2002 memorandum, the Wisconsin ARNG requested a medical review board for retention regarding the Veteran. The diagnosis was aortic stenosis. It was anticipated that he would have recovered by January 2002. He was very stable and had a pacemaker device that was functioning well. In a May 2002 statement to VA, the Veteran said that he had heart problems in the past two years. He contended that his heart problems were due to his service-connected hypertension. He reiterated his assertions in subsequent correspondence. In January 2003, he asserted that his heart condition became apparent during active duty from October 1985 to April 1990, on Title 10 reserve active duty during the Desert Storm era 1990 to 1992, and on multiple 179-day active duty (reserve) periods throughout 1993. In a September 2002 statement, the Veteran said he was first told he had a heart problem during a National Guard physical examination in March 2001, and he had taken Coumadin for this since November 2001. In a December 2002 buddy statement, another Veteran, T.S. stated that he was deployed with the Veteran for a two-week annual training in Panama in February 1995, to construct bridges. He said that the temperature was in the high 90 degrees there, with high humidity, and in the middle of the first day, the Veteran passed out from the intense heat and sun. For three days, he was assigned to quarters with the medic. He recalled that the Veteran had slight sunstroke along with high blood pressure. On day three he was improved, and worked in a covered and shaded area for the remainder of the training. On VA heart examination in June 2003, the examiner noted that the Veteran served on active duty in the U.S. Army from October 1985 through April 1990, and was then in the National Guard until his discharge. The examiner stated that the veteran had a bicuspid aortic valve which necessitated replacement of his aortic valve in October 2001 at a private hospital. Because his natural valve was replaced with a prosthetic St. Jude valve, he needed to be on lifelong anticoagulation medication with Warfarin, which he was currently taking. Because of his need for continuous anticoagulation he was deemed not fit for further military service. The Veteran contended that his aortic stenosis was aggravated by his untreated hypertension which was found in the military. On examination, his heart was in sinus rhythm with a loud click from his prosthetic valve. No murmur was audible. There was a permanent cardiac pacemaker placed in the left anterior chest area in the pectoral region. An ECG revealed bifascicular block with a pacemaker spike. The diagnostic assessment was that he had a long history of hypertension that was currently well controlled on medication, and aortic stenosis as a result of a congenital bicuspid aortic valve. The examiner indicated that the Veteran developed a small aneurysm in the ascending aorta just beyond the stenosed valve, which was the result of the high pressure jet of blood that came through the stenosed (stiff and narrowed) aortic valve. He stated that the Veteran's bicuspid aortic valve is a congenital problem, meaning that the Veteran was born with this condition. He opined that his hypertension was not the direct cause of the aortic stenosis, nor did it aggravate the problem, and that his military service did not unduly aggravate nor accelerate the progression of his aortic stenosis. VA outpatient treatment records reflect that in December 2009, he was seen for annual follow-up of his aortic valve replacement, pacemaker, elevated blood pressure, and anticoagulation therapy. He said he remained active with remodeling projects, and he was not been monitoring his blood pressure at home. On examination, his blood pressure was 160/96, and on repeat was 160/88. On cardiac examination his heart had a regular rate and rhythm, with a loud aortic valve click across the chest. The diagnostic assessment was elevated blood pressure, and he was advised to follow up with cardiology regarding his aortic valve as scheduled. In April and July 2010, improved blood pressure control was noted. VA medical records dated from February to July 2011 reflect that the Veteran had a prolonged hospitalization due to a bacterial infection of his prior AVR. In February 2011, he underwent a surgical procedure to replace his infected St. Jude aortic valve with a composite aortic graft, replacement of aortic valve and aorta with an aortic valve homograft, removal of his pacemaker and pacemaker leads, debridement of his tricuspid valve and closure of a patent foramen ovale. He was given antibiotics and later received another pacemaker. He was later diagnosed with AVR with redo and complications due to MRSA endocarditis. He was subsequently hospitalized until November 2011 for other complications. In a March 2012 statement, the Veteran said that Dr. Y. told him that long-term hypertension contributed to and aggravated his aortic stenosis and aortic aneurysm disease. The Veteran also stated that he had researched the health effects of hypertension, and found that it can result in many serious issues including heart disease. He contended that since his hypertension was not treated, he had suffered severe damage to his health. By a letter dated in October 2012, W.W.Y., MD, stated that he saw the Veteran in October 2012 and discussed his extensive medical history. He observed that the Veteran was noted to have blood pressure around 150-160/120 on numerous occasions in Florida in 1986, but his blood pressure was never treated for the next 15 years, though those examining him were certainly aware of this. He opined that the Veteran's untreated hypertension certainly could be related to the multiple cardiac problems he has had over the past several years. He noted that the Veteran had undergone heart surgery on several occasions, including in 2011. The Board finds that this medical opinion is equivocal, and expressed in speculative language, and therefore does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In his March 2014 substantive appeal, the Veteran said he did not dispute the fact that he had a congenital heart problem, but maintained that his condition was aggravated above and beyond the normal progression of the condition by his service-connected hypertension, which was largely uncontrolled. He asserted that greater weight should be given to Dr. Y.'s opinion than to the VA examiner's opinion as Dr. Y. had been his personal physician for a long time. In June 2014, the Veteran submitted a letter dated on May 31, 2014 which is purportedly from Dr. Y. The Board observes that unlike Dr. Y.'s prior two letters that are on file, the May 2014 letter is not on Dr. Y's letterhead stationery, the font is different, his signature appears different than in his letters dated in 2001 and 2012, and the zip code of his address under his signature is incorrect when compared to the other two letters. The letter is to the effect that Dr. Y. treated the Veteran before and after his military service, and the Veteran had blood pressure of 144/90 during his deployment in Germany, and was told that he was hypertensive. The letter states that the Veteran continued to serve doing heavy work till the time of discharge when he still had top scores on physical fitness tests. "However, his hypertension which had not been treated, led to surgical repair of an aortic arch aneurysm and aortic stenosis on 29 October 2001 under private insurance." The letter concludes with the statement that "[The Veteran], in my opinion, has heart damage and renal failure as a result of non-treatment during his distinguished military career. He should certainly be eligible for Veteran's benefits in light of this." In a July 2014 written statement, the Veteran reiterated many of his assertions. He said that a large ascending aorta was noted during service in May 1986, and after that he performed demanding military duties for 15 years, but never experienced any chest pain during this time. He stated that he understood that he was born with a congenital defect with his heart valve from birth but that the Army did not tell him about his enlarged ascending aorta during the period from May 1986 to March 2001, and contended that his untreated hypertension aggravated his aneurysm to dangerous degree. He contended that his military physicians overlooked his known health problems of high blood pressure and enlarged ascending aorta. He said Dr. Y. told him that his untreated hypertension aggravated his aortic valve disease and my enlarged ascending aneurysm of the aorta. He asserted that it is very well known that hypertension initiates the aortic stenotic process by damaging the valve and continues the progression. In another June 2014 statement, the Veteran said that he had conducted extensive internet research and found many articles linking hypertension, valve disease, aortic stenosis, and aortic aneurysm, and stated that long-term hypertension is a well-established risk factor for cardiovascular events. He noted that a May 1986 service treatment record showed elevated blood pressure and an enlarged ascending aorta, but contended that his military doctors did not properly examine or treat these conditions or diagnose his bicuspid aortic valve disease. He contended that if he had been properly treated, his hypertension might have been corrected and prevented his aorta from growing larger. At the July 2014 Board hearing, the Veteran reiterated many of his contentions. He testified that an enlarged aorta was noted in service in May 1986 but was never treated, along with hypertension. He said he was not aware of any congenital heart issue when he entered service. He stated that Dr. Y. reviewed his service treatment records dated in 1986. His representative argued that Dr. Y's opinion is probative, because he had access to his service medical records, and he was his long-time physician. He stated that Dr. Y. told him that his service-connected and mostly uncontrolled hypertension, was the cause of the exacerbation of his congenital aortic condition. His wife stated that his first heart surgery was in 2001, and in 2011, he had to have two open heart surgeries in less than a month. His representative contended that his aortic heart condition began and was diagnosed during service in 1986, but it was not treated. Alternatively, she contended that the heart condition was caused or aggravated by service-connected hypertension. The Veteran testified that Dr. Y. told him that his longstanding hypertension caused his heart problems. The Board remanded this appeal in February 2015 for another VA examination as to the etiology of the current heart conditions. When reopening the previously denied claim of service connection for a heart disability, the Board presumed the credibility of the May 2014 letter purportedly from Dr. Y., pursuant to Justus v. Principi, 3 Vet. App. 510, 513 (1992), and then found it to be new and material evidence. On VA compensation examination in May 2015, the Veteran was examined and his claims file was reviewed. Hypertension was diagnosed, and he had reportedly been taking Metoprolol since 2001 for control of his hypertension. The VA examiner diagnosed the following heart conditions: heart block (diagnosed 2001), valvular heart disease (diagnosed 2008), and heart valve replacement (2001). Pertinent medical records, including service treatment records, were summarized by the examiner. A physical examination was performed, and a chest X-ray study showed a sternotomy, surgical clips over the mediastinum, and a pacemaker with leads in the right atrial and ventricular regions. Temporary leads were also noted over the heart. Heart size and pulmonary vascularity were within normal limits. An echocardiogram showed cardiac hypertrophy. The VA examiner opined that the claimed heart condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale was that the Veteran's diagnosed bicuspid aortic valve, described as a congenital defect, was less likely as not caused by service factors at the time of his diagnosis (2001) since his heart valve condition is congenital in nature, and which therefore had its onset before service and not within one year of service separation. The examiner stated that he could not determine a baseline level of severity of the claimed condition based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by the service-connected condition. The examiner opined that the Veteran's claimed condition was not at least as likely as not aggravated beyond its natural progression by hypertension. The rationale was that the Veteran's diagnosed bicuspid aortic valve, described as a congenital defect was less likely as not aggravated beyond its natural progression by service factors at the time of his diagnosis (2001) since the heart valve condition is congenital in nature and which therefore had its onset before service and not within one year of service separation. The May 2015 VA examiner also opined that the Veteran's claimed diagnosed bicuspid aortic valve, described as a congenital defect, was less likely as not caused or aggravated beyond its natural progression by service factors/superimposed disease or injury that began during or is otherwise the result of the Veteran's military service or hypertension condition since his blood pressure had been treated following active duty service during "2012-1997 ('next 15 years')" and was deemed as well-controlled by his own physician (Toprol XL in 2001), and his service treatment records showed blood pressure treatment during active duty service. The examiner indicated that the suggestion by the Veteran's primary care provider that "the untreated hypertension" could be related to the multiple cardiac problems was not supported by specific medical records or diagnoses and was to the exclusion of any confounding conditions to such effect, because significant hypertension should manifest as hypertensive heart disease which has not been diagnosed, and because the Veteran's lay statements have no predictive accuracy or reliability for the establishment of any specific diagnosis or onset (heart valve condition 2001). Ultimately, the Board must consider all the evidence relevant to the claim, including the availability of medical records, the nature and course of the disease or disability, the amount of time that has elapsed since military service, and any other pertinent facts. Cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact-finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). It is the Board's province to determine the credibility of evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007) ("The Board retains discretion to make credibility determinations and otherwise weigh the evidence submitted [.]"). In making credibility determinations, the Board may consider factors such as facial plausibility, bias, self-interest, and consistency with other evidence of record. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The Board may consider the absence of contemporaneous medical evidence when determining the credibility of lay statements, but may not determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence. The presumption of soundness when entering service attaches only where there has been an induction examination during which the disability about which the Veteran later complains was not detected ("noted"). See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The presumption of soundness shields the Veteran from a finding that the disease or injury preexisted (and therefore was not incurred in) service by requiring the Secretary to prove by clear and unmistakable evidence that a disease or injury manifesting in service both preexisted service and was not aggravated by service. See Gilbert v. Shinseki, 26 Vet. App. 48, 55 (2012). The presumption of soundness attaches only when the condition at issue is not noted at entrance into service and the condition is determined to have manifested in service. Id. at 54. However, the presumption of soundness does not apply to congenital defects, as a defect is defined as a condition that is not capable of deterioration. See 38 C.F.R. § 3.303(c); VAOPGCPREC 82-90 (July 18, 1990) (finding that hereditary defects are excluded from VA compensation benefits by 38 C.F.R. § 3.303(c)). Congenital or developmental defects, refractive error of the eye, personality disorders and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. § 3.303(c). The evidence reflects that a cardiac condition was not noted on entrance examination in October 1984, prior to the Veteran's first period of active duty service, and he is thus presumed to have been in sound condition at entry to that period of service, with the exception of any congenital defects. The initial question is whether the Veteran's diagnosed bicuspid aortic valve is a congenital defect or disease. This condition was not diagnosed during either of the Veteran's periods of active duty, and was first diagnosed in 2001. Congenital defects are by definition static in nature, and thus the litmus test for distinguishing a congenital defect from a congenital disease is whether the disorder in question is subject to change. See VAOPGCPREC 67-90. As explained in the precedential General Counsel opinion, "congenital or developmental defects are normally static conditions which are incapable of improvement or deterioration." Id. The opinion states further: "A disease, on the other hand, even one which is hereditary in origin, is usually capable of improvement or deterioration." Id.; see also Quirin, 22 Vet. App. at 395 (observing that "[u]nder the framework set forth in the General Counsel opinion, any worsening - any change at all - might demonstrate that the condition is a disease, in that VA considers defects to be 'more or less' static and immutable") (citing VAOPGCPREC 82-90)). Thus, if the disorder may be aggravated, then it is not considered a congenital defect, and consequently it is eligible for service connection notwithstanding its congenital nature. See id. Superimposed disease or injury is also eligible for service connection. See VAOPGCPREC 82-90 (observing that even congenital defects "can be subject to superimposed disease or injury" and that "if during an individual's military service, superimposed disease or injury does occur, service-connection [sic] may indeed be warranted for the resultant disability"); see also Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993). VA's General Counsel has held that service connection may be granted for congenital or hereditary diseases if initially manifested in or aggravated by service. VAOPGCPREC 82-90; VAOPGCPREC 67-90. In particular, a hereditary disease does not always rebut the presumption of soundness, and, thus, diseases of hereditary origin can be incurred in service. VAOPGCPREC 67-90. According to this opinion, such diseases "can be considered to be incurred in service if their symptomatology did not manifest itself until after entry on duty." Id. The opinion went on to explain that "only when symptomatology and/or pathology exist can he or she be said to have developed the disease." Id. "In this context we use the term "pathology" in the sense of an active disease process, not just a mere predisposition to develop a disease, which process may or may not precede symptomatology." Id. The undisputed competent and credible evidence of record, including May 2015 VA examination report and the June 2003 VA medical opinion, that the Veteran was born with his congenital bicuspid aortic valve, demonstrates that it is a congenital condition that clearly and unmistakably preexisted service entrance. After his periods of active duty, in August 2001, Dr. Y. diagnosed aortic stenosis and aortic aneurysm, and the Veteran underwent AVR in October 2001, with permanent pacemaker placement. The June 2003 VA examiner explained that the Veteran's aortic stenosis was the result of his congenital bicuspid aortic valve, and that he developed a small aneurysm in the ascending aorta just beyond the stenosed valve, which was the result of the high pressure jet of blood that came through the stenosed (stiff and narrowed) aortic valve. He opined that the Veteran's hypertension was not the direct cause of the aortic stenosis, nor did it aggravate the problem, and that his military service did not unduly aggravate the progression of his aortic stenosis. An "aneurysm" is defined as a circumscribed dilation of an artery or a cardiac chamber, a direct communication with the lumen, usually due to an acquired or congenital weakness of the wall of the artery or chamber. See Stedman's Medical Dictionary, 27th ed., 2000, at 79). Based on the June 2003 VA examiner's competent medical opinion, to the effect that his congenital bicuspid aortic valve caused aortic stenosis (a stenosed valve), the Board concludes that the bicuspid valve was not static, since it became stenosed (i.e., it deteriorated). The Board finds that the examiner's opinion indicates that the Veteran's congenital bicuspid aortic valve is a disease and not a defect (a condition that is not capable of deterioration). See Quirin, supra; VAOPGCPREC 82-90. Thus, since the Veteran's congenital disease of a bicuspid aortic valve was not noted on entrance into service, but clearly and unmistakably preexisted service entrance, the remaining question is whether the Veteran's bicuspid aortic valve clearly and unmistakably was not aggravated by service. And after a thorough review of the evidence of record, the Board finds that this standard of proof is not met. In this regard, the Board notes that the June 2003 examiner indicated that the progression of his aortic stenosis was not "unduly" aggravated by service, which does not meet the required standard of proof. And the May 2015 examiner's opinion only related to the status of the claimed condition in 2001, not to its status in 1986. The evidence reflects that the Veteran had other cardiac abnormalities that first manifested during active duty service in 1986, including a prominent/large ascending aorta, a systolic ejection murmur, and an incomplete right bundle branch block shown on ECG. The Board finds that since the evidence does not undebatably show that the Veteran's preexisting bicuspid aortic valve was not aggravated by service, that the presumption of soundness is not rebutted, and the condition is deemed to have been incurred in service pursuant to the presumption of soundness. However, service connection is not warranted for any current heart disability unless the evidence is at least in equipoise that the current disability is related to the disease or injury that has been deemed service incurred. Gilbert, 26 Vet. App. at 55. It is undisputed that the Veteran's aortic valve disease continued after service, and his aortic valve required replacement in 2001, along with graft replacement of the ascending aortic aneurysmal segment. Competent and credible private and VA medical evidence have linked the AVR to his congenital bicuspid aortic valve, and he subsequently required another heart valve replacement in 2011 which is still present. Therefore, it is not necessary to further delay a final decision by attempting to further clarify the evidence, which is insufficient to support a denial. Instead, the evidence as it currently stands is essentially evenly balanced. As such, there is a sufficient basis on which to decide the claim, and service connection for valvular heart disease with aortic valve replacement (AVR) is warranted. In reaching this determination, the benefit-of-the-doubt rule has been applied. 38 U.S.C. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board also finds that the weight of the competent and credible evidence does not link any other current heart disability to service or a service-connected disability, to include hypertension. In October 2012, Dr. Y. opined that the Veteran's "untreated hypertension" certainly could be related to the multiple cardiac problems he has had over the past several years. The Board finds that this medical opinion is equivocal, and expressed in speculative language, and therefore does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Moreover, it is based on an unsubstantiated account (i.e., that the Veteran's hypertension was not treated in service). See Swann v. Brown, 5 Vet. App. 229, 233 (1993) (medical opinion premised on unsubstantiated account is of no probative value and does not serve to verify the occurrences described). Service treatment records show that the Veteran did receive medication for hypertension in service. The May 2015 VA examiner has indicated that records showed that the Veteran's hypertension was treated during service, and that the Veteran does not have hypertensive heart disease, which would be expected if he in fact had significant hypertension. A careful review of the May 2014 letter purportedly from Dr. Y. reveals that it is not written on Dr. Y's letterhead stationery, his signature appears different than in his letters dated in 2001 and 2012, the font is different than his prior letters, and the zip code of his address under his signature is incorrect when compared to the other two letters. The Board therefore accords this letter no probative weight, as it does not appear that it was written by Dr. Y. Finally, although the Veteran himself has asserted that all of his current heart disabilities are related to longstanding hypertension, he has not been shown to have the necessary training or expertise to competently provide a medical nexus opinion as to the etiology of his current heart disabilities, which are not the type of conditions that are readily amenable to probative lay comment regarding its appropriate diagnosis and etiology. In sum, service connection is warranted for valvular heart disease, status post AVR. Spine Disability The Veteran contends that his current back disability was incurred in service as a result of an injury in June 2000. He asserts that he hurt his back when another soldier threw a wet camouflage net at him, and it caught him wrong, wrenching his back and causing severe pain. He said he went to the medical officer, and was limited to his quarters and put on the sick list. He said the other soldier was disciplined. He contended that from that time to the present, his back condition had worsened, and he had been treated at a VA facility since February 2010. He denied other treatment for this condition. See his July 2010 statement. A review of the medical evidence reflects that the Veteran has a current back disability. Consequently, the determinative issue is whether or not the current back disability is attributable to his military service. Service personnel records show that the Veteran served on active duty from October 1985 to April 1990, and from June 1992 to September 1993. He had additional reserve service in the Army National Guard (ARNG) of Wisconsin from April 1990 to May 2002, when he was found medically unfit for retention due to a cardiac condition. Service treatment records from the Veteran's periods of active duty are negative for a back injury or disability. In a February 1990 report of medical history, the Veteran denied a history of recurrent back pain. His spine was normal on concurrent discharge examination. Because the Veteran's National Guard training duty was only occasional, the onset of his claimed condition must be related to a specific period of training duty. National Guard duty is distinguishable from other Reserve service in that a member of the National Guard may be called to duty by the governor of his state. Members of the National Guard only serve the federal military when they are formally called into the military service of the United States; at all other times, National Guard members serve solely as members of the State militia under the command of a state governor. Allen v. Nicholson, 21 Vet. App. 54, 57-58 (2007). Therefore, to have basic eligibility for Veterans benefits based on a period of duty as a member of a state National Guard, a National Guardsman must have been ordered into Federal service by the President of the United States, see 10 U.S.C. § 12401, or must have performed "full-time duty" under the provisions of 32 U.S.C. §§ 316, 502, 503, 504, or 505. See 38 U.S.C.A. §§ 101(21), (22)(C); Allen, supra. In this case, the Veteran's service personnel records reflect that he was ordered to annual training in the Wisconsin ARNG from June 3, 2000 to June 17, 2000, pursuant to 32 U.S.C. § 503, and basic eligibility is shown. Service treatment records reflect that on June 11, 2000 the Veteran suffered a back injury. A statement of medical examination and duty status reflects that he overstrained his back muscle while moving a camouflage screen. The medical examiner opined that the injury was incurred in the line of duty, and that the Veteran's injury was not likely to result in a claim against the government for future medical care. It was noted that he was on ACDUTRA, under the authority of 32 U.S.C. § 503 at the time of the incident. The examiner indicated that low back pain was incurred on a field exercise from operating the SEE excavator, and his possible muscle strain was treated with Motrin. In a signed June 12, 2000 statement, another soldier, T.S., stated that he was in the HEMMET and was unloading camo screens off the HEMMET and storing them in the barracks. He said he tossed them and one hit the Veteran as he tried to catch one, and it "goofed" up his back and he was hurt. A June 12, 2000 sick slip reflects that the Veteran had a possible back strain while offloading a cam screen. A June 12, 2000 service treatment record reflects that the Veteran complained of left low back pain from working on a SEE the previous day. He said Motrin helped a little. On examination, he had discomfort in the low back. The diagnostic assessment was possible muscle strain. Service personnel records dated in July 2000 reflect that the injury was determined to have been incurred in the line of duty. On service medical examination in March 2001, the Veteran's spine was normal. In a March 2001 report of medical history, the Veteran denied recurrent back pain or any back injury. Post-service medical records are negative for complaints, treatment or diagnosis of a back disability until 2010. The Veteran filed his original claim of service connection for a back disability in July 2010. In a September 2010 statement, he said that he was claiming service connection for an upper and lower back condition. He said that the net incident originally affected his low back, but he believed it had subsequently affected his entire back. He stated that he had constant chronic back pain, and he was able to live with his back problems between discharge until about February 2010 when his pain increased. VA medical records dated in 2010 reflect that an April 2010 X-ray study of the cervical spine showed degenerative disc disease. In August 2010, he was seen for complaints of upper back, shoulder and neck pain. An August 2010 X-ray study of the lumbosacral spine was performed for the Veteran's complaints of low back pain, and showed degenerative disc disease with osteophytic spurring at L1-2, and retrolisthesis at L5-S1. An October 2010 computed tomography (CT) scan of the lumbar spine showed multilevel spondylosis most prominent at L4-L5, and mild dextroscoliosis with low-grade anterolisthesis of L4 on L5. A January 2011 X-ray study of the thoracic spine reflects that there was no acute osseous abnormality in the thoracic spine, and mild degenerative changes in the thoracic spine. A report of a January 2011 VA compensation examination shows that the Veteran reported a history of a chronic upper and low back condition since a June 2000 injury during annual training that occurred when he was unloading a wet camouflage screen from a truck. He stated that he was standing on the ground behind a 2-1/2-ton truck when another soldier threw down a large amount of camouflage screen that crunched his upper and low back to the ground. He said his back eventually got better, but had been a source of complaints of upper or low back pain off and on since then. He had not gone to any other healthcare specialists except his primary care physician over the last several years. He denied any new injuries to his neck or back since military service. He felt that his upper low back had worsened in the last three years. The examiner summarized the findings on the October 2010 CT scan and on X-ray study in January 2011, and then diagnosed chronic upper thoracic left paravertebral myofascial strain with mild thoracic degenerative spine disease, and multi-level lumbar degenerative spine disease. The examiner opined that it was less likely as not that the Veteran's upper low back condition was related to his injury in 2000. The examiner's rationale was that the Veteran reported that he got better, therefore while he did report chronic low back pain, due to the lack of documentation within the first few years after that injury of any ongoing treatment or care it is less likely as not that his back injury in the year 2000 did not [sic] cause any chronic residual problems. He added that conditions documented only a few times in the service treatment records that did not result in medical discharge and without documentation of ongoing medical care within five years of military discharge are most likely to have been resolved self-limited conditions. In his February 2013 substantive appeal, the Veteran asserted that service connection was warranted because VA had conceded and verified his in-service back strain, the VA examiner had diagnosed back strain, and there were VA medical records showing treatment for back strain. He asserted that he hurt himself while working on "active duty" with the WI Army National Guard and had additional service in the Guard for the next two years. He stated that he did not seek care immediately following the incident because it seemed to get better with medication (Motrin) and "seemed resolved." He contended that the condition later returned in the same exact spot with the same symptoms, and worsened over time. He asserted that the current disability started with his in-service injury. With regard to the multi-year period during which he did not seek treatment or file a claim, he said he ignored the condition, self-medicated, and avoided activities until the condition became unbearable, and then sought care and filed his claim. He suggested that this was common behavior. In a March 2014 statement, he contended that his VA examiner did not consider his lay statements regarding his longstanding back pain for which he treated himself. He asserted that many other Veterans do the same thing, and only seek treatment when it becomes absolutely necessary. The Veteran stated that he had two tours of active duty followed by a combination of National Guard and Army Reserve duty, and served in uniform from discharge from active duty until approximately December 2002, when he was retired from the Army Reserve. He said that although VA considered him to be civilian for much of the time, he was in fact still in uniform. A July 2014 X-ray study of the thoracic spine showed degenerative spurring, but was otherwise negative. At the July 2014 Board hearing, the Veteran testified that during maneuvers in service at Camp McCoy, his back was injured in an incident in which he and another soldier were removing rain-sodden nets from a truck, and the other man tossed one of the wet nets at him, and it knocked him down to the ground. He said it crushed him. He said his back cracked at the time, and he heard a crack. He was sent to the "TMC" and given Motrin, which helped, but he did not see a doctor. When he finally got out of his barracks the next day, he had improved enough to get around. He did not do any work afterward, until he returned home. After that incident, he worked in the military "full time," and his back improved, and he just took Aleve for it, which worked really well for the pain, and he took it as needed. He said he kept a bottle of Aleve in his toolbox at work in the military. He said that he never complained about it because he did not want to be discharged because of it. He said the problem continued, then worsened, became really bad about four years ago, and was even worse currently. He stated that the net incident was when his back problem really began, but he recovered from that to a certain extent. See hearing transcript, page 10. He said that afterward, his back pain varied in intensity, and was worse on some days than others. His representative stated that after active duty the Veteran worked with the National Guard in a full-time capacity, and did not complain about the back problems, because he was afraid he would lose his job. He continued to work with heavy equipment and heavy machinery, and experienced back pain throughout his career. His representative asserted that the Veteran denied back pain on his periodic examination in 2001 because he did not want to lose his job. The Veteran contended that he had back symptoms ever since the 2000 injury. The Veteran's wife testified that when the Veteran came home in 2000, after this injury, his back was basically never the same, and lately was worse. He can hardly even get up easy from the chair. The Veteran's wife testified that when he returned home after the injury, he was sore for almost a whole week, and did not go to work. The Veteran agreed with this statement. The Veteran's wife testified that afterward, he had ongoing symptoms of back pain, and treated himself with over-the-counter medication. The Veteran testified that he never had any back problems prior to this injury, despite his duties which involved heavy lifting. The Board remanded this appeal in February 2015 for another VA examination as to the etiology of the current back disability, and the examiner was asked to consider the Veteran's competent lay statements regarding continuous back symptoms since his back injury. A May 2015 chest X-ray study showed degenerative changes in the thoracic spine. The file contains several reports regarding a VA spine examination conducted by the same examiner in May 2015. The VA examiner indicated that the Veteran was examined and the claims file was reviewed. The examiner noted that the Veteran, a retired mechanic, walked into the appointment unaided presenting in no apparent distress and with normal gait. He reported localized lower back pain for which he takes Tramadol which does not work as well as the Vicodin which he states he previously was prescribed. His pain was fairly constant but aggravated by movement. He reinjured his back when he fell on a roofing job about a year ago. His back pain was now localized in his lower back but affected his neck and shoulders to a greater degree. The Veteran states that his back pain first started when heavy (more than 100 pounds), wet nets were thrown on top of him by another National Guard member in 2000. He said he went crushing to the ground and needed help getting up. He was on bedrest for the balance of the day and was placed on light duty for the rest of his term of about three days. He took Aleve/over-the-counter medication for his condition at that time, and he continued to take this medication for some time. He was not sure when he first started seeing physicians about his back condition. He stated that his back condition became more painful during his extended hospitalization in 2011, and he began taking Vicodin. He reported that he was treated by a chiropractor/therapist about five years ago, when he had a painful neck "snapping" incident. He stated that ever since that incident, he had persistent pain with lateral neck motion. He said he had not worked since 2006, and had previously worked as a military technician, handyman, and mechanic. The examiner diagnosed lumbosacral strain, degenerative arthritis of the spine, and degenerative arthritis. In another examination report, the VA examiner noted that the claims file and medical records were reviewed. The examiner opined that the claimed back disability was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale was that the Veteran's claimed back pain condition is more likely as not (50 percent or greater probability) caused or aggravated beyond its natural progression by service factors since the Veteran states that his back pain commenced at the time of his 2000 injury documented in the service treatment records, and because Veteran's lay statements regarding onset are deemed competent, but which nonetheless have no predictive accuracy or reliability for the establishment of any specific diagnosis or onset, apart from pain, which is a self-reported and subjective condition/symptom. In a subsequent VA examination report dated the same day, the May 2015 VA examiner opined that the claimed back condition of thoracic spine degenerative arthritis was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner stated that the Veteran's diagnosed thoracic spine degenerative arthritis (diagnosed in 2011) is less likely as not caused by service factors since his service treatment record "MOI" was self-limited, there is no documentation of back care proximal to service discharge such as would constitute a chronic disability, his service exit examination was normal, arthritis was not diagnosed within one year of active duty separation, and interceding factors cannot be excluded. The examiner concluded that although the Veteran's lay statements regarding onset of pain have been deemed competent, they have no predictive accuracy or reliability for the establishment of any specific diagnosis or onset other than pain. Although the Board finds that the May 2015 VA examiner's multiple reports are confusingly written, and contain extensive excerpts from other medical records, it appears that the VA examiner has determined that the Veteran had chronic back pain ever since his June 2000 in-service injury, which was likely related to service, but that his thoracic spine degenerative arthritis was not likely related to service. In Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) recognized lay evidence as potentially competent to support the presence of the claimed disability, both during service and since, even where not corroborated by contemporaneous medical evidence such as actual treatment records (e.g., STRs, etc). The Federal Circuit Court has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Board therefore may consider the absence of any indication of a relevant medical complaint until relatively long after service as one factor, though not the only or sole factor, in determining whether a disease or an injury in service resulted in chronic or persistent residual disability. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). See also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (cautioning that negative evidence, actual evidence weighing against a party, must not be equated with the absence of substantive evidence). Considering the positive May 2015 medical nexus opinion, the competent and credible lay statements and testimony by the Veteran and his wife as to continuity of back symptoms since his documented in-service injury in the line of duty during a period of ACDUTRA, and the current diagnoses of arthritis of the spine, the Board finds that the medical and lay evidence concerning the determinative issue of whether the current back disabilities of multi-level lumbar degenerative spine disease, upper thoracic left paravertebral myofascial strain, lumbosacral strain and degenerative arthritis of the thoracic and lumbosacral spine were incurred in or aggravated by service are at least in relative equipoise, i.e., about evenly balanced for and against his claim. Consequently, resolving all reasonable doubt in his favor, the Board finds that service connection is warranted for these disabilities. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); see also 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303(b) (2015); Walker, supra. As a result, the appellant has achieved Veteran status as to the June 3, 2000 to June 17, 2000 period of ACDUTRA, as he has established that he was disabled from disease or injury incurred or aggravated in the line of duty during that period. ORDER Service connection for valvular heart disease with aortic valve replacement (AVR) is granted. Service connection for multi-level lumbar degenerative spine disease, upper thoracic left paravertebral myofascial strain, lumbosacral strain and degenerative arthritis of the thoracic and lumbosacral spine is granted. ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs