Citation Nr: 1647973 Decision Date: 12/23/16 Archive Date: 01/06/17 DOCKET NO. 07-00 257 A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for a bilateral knee disability, to include as secondary to a service-connected disability. 2. Entitlement to service connection for a bilateral foot disability, to include as secondary to a service-connected disability 3. Entitlement to service connection for a bilateral hand disability, to include as secondary to a service-connected disability. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD M. Timbers, Associate Counsel INTRODUCTION The Veteran had active duty service from May 1980 to May 1982 with the United States Army. This appeal comes to the Board of Veterans' Appeals ("Board") from an April 2006 rating decision by the Department of Veterans Affairs ("VA") Regional Office ("RO") in Jackson, Mississippi (hereinafter Agency of Original Jurisdiction ("AOJ")). The issues on appeal have twice been before the Board. First, in September 2010, the Board remanded the issues to the RO for further development, including the procurement of relevant VA treatment records and relevant private treatment records. The issues on appeal were subsequently returned to the Board in September 2015. Then, in January 2016, the Board remanded the issues to the RO in order for the Veteran to be afforded with VA examinations to assess the etiology of the Veteran's knees, hands, back, and feet disabilities. These examinations were scheduled and their findings were added to the Veteran's claims file. Similarly, throughout the pendency of the appeal, updated VA treatment records were added to the Veteran's claims file. Therefore, as the requested development was completed, and the matter has been properly returned to the Board, the Board finds appellate consideration may proceed without prejudice to the Veteran. See Stegall v. West, 11. Vet. App. 268 (1998). Additionally, in January 2016 the Board remanded the Veteran's claim for entitlement to service connection for a low back disability, to include as secondary to his service-connected disability of transitional lumbosacral segment with sacroilitis. In a March 2016 rating decision, the RO granted the Veteran's claim for service connection. Because this constitutes a full grant of the issue sought on appeal, the claim of service connection for a low back disability is no longer before the Board. An informal hearing was held before a Decision Review Officer at the Jackson, Mississippi RO in April 2008. A transcript of the hearing is associated with the Veteran's claims file This appeal was processed using the paperless Veterans Benefit Management System ("VBMS") and Virtual VA claims processing systems. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The issue of entitlement to service connection for a stomach disorder has been raised by the record, but has not been adjudicated by the AOJ. See June 2016 Notice of Disagreement. Therefore, the Board does not have jurisdiction over this issue and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran's current right knee disorder began during, or was otherwise caused by, his active service. 2. The Veteran has not had a diagnosed left knee disorder during the appeal period or within proximity thereto. 3. The weight of the evidence is against a finding that the Veteran's currently diagnosed bilateral foot disorder either began during, or was otherwise caused by, his military service or a service connected disability. 4. The weight of the evidence is against a finding that the Veteran's currently diagnosed bilateral hand disorder either began during, or was otherwise caused by, his military service or a service connected disability. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in his favor, the Veteran has a right knee disability which was incurred during active service. 38 U.S.C.A. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 2. A left knee disability was not incurred in or aggravated by the Veteran's active duty service, nor may a left knee disability be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 3. The criteria for service connection for the Veteran's bilateral foot disorder have not been met. 38 U.S.C.A. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2015). 4. The criteria for service connection for the Veteran's bilateral hand disorder have not been met. 38 U.S.C.A. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 ("VCAA"), the VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015). The VCAA required notice provisions were accomplished by numerous letters, including letters dated in March 2006 and September 2008, which informed the Veteran of the information and evidence not of record that is necessary to substantiate the claim, the information and evidence that the VA will seek to provide, and the information and evidence the Veteran is expected to provide. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). The letters also informed the Veteran how disability ratings and effective dates were established. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied. Pertinent to the VA's duty to assist, the record also reflects that the VA has undertaken appropriate actions to obtain all relevant evidence material to this claim. The RO has secured the Veteran's service treatment records ("STRs") and VA treatment records. Additionally, the RO has secured the Veteran's application for Social Security Disability and the relevant medical evidence associated with that application. The Veteran was afforded a VA examination in May 2016 in connection with the claim addressed herein. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 U.S.C.A. § 5103A (d)(2); 38 C.F.R. § 3.159(c)(4). This examination and the medical opinions provided were thorough, supported by a clear rationale, based on a review of the claims folder, and supported by the clinical evidence of record. Additionally, the VA examiner considered the Veteran's lay assertions in reaching his conclusion. Therefore, the Board finds that these medical opinions are adequate to decide the claims on appeal. For his part, the Veteran has submitted personal statements regarding his symptoms and limitations. The Veteran has additionally submitted statements from three of his co-workers. As was also noted above, the Veteran's claim was previously remanded by the Board in September 2010 and January 2016. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). The Board remanded the Veteran's claims in order to obtain VA and private treatment records and to obtain VA medical examinations. To that end, the evidentiary record now contains updated Veteran's VA treatment records, and VA examinations. Accordingly, the VA has substantially complied with the September 2010 and January 2016 remand directives. However, the Board notes the Veteran has alleged his claims file is "missing" private treatment records. See June 2016 Notice of Disagreement. In this letter, the Veteran does not provide the dates of treatment or what he received treatment for. As part of the Board's September 2010 remand, the RO was directed to obtain updated private treatment records, in addition to updated VA treatment records. In a letter dated December 2010, the RO requested the veteran to identify any outstanding private medical records, especially those referenced in the Board's September 2010 remand order. However, no response was received from the Veteran. Subsequently, the Veteran submitted a letter in July 2014 which requested the VA wait 30 days from the date of his SSOC, but also explicitly stated he had no additional medical records to submit. See July 2014 Correspondence. Similarly, following the Boards January 2016 remand, the Veteran submitted an addition statement requesting his appeal be expedited and stating there were no additional medical records to submit. Therefore, despite the Veteran's June 2016 notice of disagreement, the Boards finds the VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Despite numerous communications and attempts to the Veteran, he has not provided any information about his private treatment records which could be used to obtain them. Furthermore, the Veteran himself has declared twice that there is no additional outstanding medical evidence relevant to his current appeal. In this regard, the Board notes the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. In summation, the Board finds the duties imposed by the VCAA have been considered and satisfied. The Veteran has been notified and made aware of the evidence needed to substantiate this claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain, or development required, to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Entitlement to Service Connection: The Veteran is seeking service connection for a bilateral knee disability, bilateral foot disability, and a bilateral hand disability. In seeking VA disability compensation, a Veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Establishing service connection on a direct basis generally requires competent evidence showing: (1) the existence of a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381, F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d); See also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). That is to say, some diseases are chronic, per se, such as arthritis, and therefore will be presumed to have been incurred in service, although not otherwise established as such, if manifested to a degree of ten percent or more within one year after service. Even this presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Additionally, VA regulations allow for a current disability to be service connected if the evidence of record reveals the Veteran has a current diagnosis that was chronic in service, or, if not chronic, that was seen in service with continuity of symptomatology demonstrated thereafter. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). A demonstration of continuity of symptomatology is an alternative method of demonstrating the second and/or third elements discussed above. Savage, 10 Vet. App. at 495-496. A Veteran may alternatively establish service connection on a secondary basis, for a condition that is not directly caused by the Veteran's service. 38 C.F.R. § 3.310. That is, secondary service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disorder. 38 C.F.R. § 3.310(a). Secondary service connection may be found in certain instances in which a service-connected disability aggravates another condition. 38 C.F.R. § 3.310(b). The determination of whether the requirements of service connection have been met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). In making these determinations, the Board must consider and assess the credibility and weight of all evidence in the claim file, including the medical and lay evidence, to determine its probative value. In doing so, the Board must provide its reasoning for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Barr v. Nicholson, 21 Vet. App. 303 (2007). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2015). A claimant need only demonstrate an approximate balance of positive and negative evidence in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For a claim to be denied on the merits, a preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). That being the relevant law for the Veteran's claims of entitlement to service connection, the Board will discuss the merits of each claim separately. I. Bilateral Knee Disability The Veteran seeks entitlement to service connection for a bilateral knee disability. Specifically, the Veteran alleges that the arthritis from his back has spread down through his legs and into his bilateral knees. See January 2006 Statement in Support of Claim. The Veteran has alleged that his pain and stiffness has progressively worsened since his separation from active duty service. Currently, he wears knee braces on a daily basis to keep the swelling down and for stability while walking. See June 2016 Notice of Disagreement. As will be discussed in further detail below, the Board finds that the evidence for and against the Veteran's claim for service connection for arthritis of his right knee is at the very least in relative equipoise, and reasonable doubt will therefore be resolved in his favor. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. However, the Board finds that the competent and credible evidence show no diagnosis for the Veteran's left knee, and therefore, he is not entitled to service connection for his claimed left knee disability. a. Right Knee After a thorough review of the evidentiary record, the Board finds the Veteran is entitled to service connection for his right knee disability. Specifically, the Board finds the competent and credible evidence of record, which includes both medical evidence and the Veteran's lay assertions, documents probative evidence of chronic symptomatology since his separation from active military service. See Savage v. Gober, 10 Vet. App. 488 (1997). The Veteran's STRs show he consistently sought treatment for complaints of back pain, which radiated down into his hips and knees. These records show the Veteran injured his back while in service, after lifting a trailer hitch. See STRs Dated November 1981. Subsequent records demonstrate the Veteran continued to complain of radicular pain, into his legs and knees, throughout his active duty service. For example, the Veteran complained of pain in his right knee while running in January 1982. Based on these records, the Board finds there is some evidence of an in-service occurrence of the Veteran's current right knee pain. The Board finds the Veteran has submitted several lay statements in which he asserts his knee symptoms have been continuous since his active military service. As a lay person, the Veteran is considered to be competent to report what comes to him through his senses, such as knee pain and swelling. Layno v. Brown, 6 Vet. App. 465 (1994). In a January 2006 statement, the Veteran alleged the pain and stiffness in his knee has progressively worsened since his separation from active duty service. The Veteran has made similar statements throughout the appeal, consistently relating his current knee disability to his active duty service, specifically the accident to his lower back. The Veteran's lay assertions are also supported by the medical evidence of record. Since his separation from active military service the Veteran has consistently sought medical treatment for complaints of back pain, which radiated into his legs. See VA Treatment Records, Dated 1985-2000. Notably, the Veteran began seeking medical care and treatment for complaints of back pain, with radiating pain into his legs and knees in May 1985. A careful review of these records shows the Veteran reported symptoms of knee pain and swelling resulting from his back injury during his military service. Subsequent medical records show the Veteran was diagnosed with right knee osteoarthritis. For example, radiographs of the Veteran's bilateral knees were taken in August 2004, which showed narrowing within the femoral tibial joint space of the right knee. See Jackson VAMC Records. Based upon this image, the Veteran was diagnosed with early osteoarthritis of the right knee. A magnetic resonance imaging ("MRI") of the right knee in September 2004 showed a "moderate amount of increased fluid" within the joint space. This MRI additionally showed some evidence a tear along the Veteran's medial meniscus. Therefore, the Board finds the evidence showed the Veteran was diagnosed with right knee osteoarthritis in August 2004, which is considered a chronic disease under 38 C.F.R. § 3.309(a). Moreover, the Board finds the medical and lay evidence of record establishes the Veteran has experienced continuity of symptoms of a right knee disability since his active military service. 38 C.F.R. § 3.303(d). The Board is aware that the more recent medical evidence reveals normal findings for the Veteran's right knee. Specifically, a July 2007 x-ray was "normal," showing no evidence of arthritis of bony abnormalities. See Jackson VAMC Records. However, the Board notes the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). Moreover, the Board finds the Veteran's lay statements with respect to his complaints of knee pain and swelling are credible and provide probative evidence of chronic symptomatology since service. See Savage v. Gober, 10 Vet. App. 488 (1997). In this regard, lay evidence is competent to establish a diagnosis only when a lay person (1) is competent to identify the medical condition; (2) is reporting a contemporaneous medical diagnosis; or (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). To that end, the Board finds that the Veteran's reports of knee pain and swelling immediately following his separation from military service are made more credible by his August 2004 diagnosis for right knee osteoarthritis. 38 C.F.R. § 3.303(d). The Board notes that May 2016 VA examination and opinion are not in favor of the Veteran's claim for service connection. Specifically, the VA examiner opined the Veteran's knee disability was not related to his military service because the recent medical imagining reports showed no evidence of any disability or abnormality. However, the Board notes the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). Therefore, the Board finds that the VA examiner's reliance on the July 2007 x-ray report of the right knee is not entitled to probative value. In conclusion, and after consideration of the above evidence, the Board finds the Veteran complained of right knee pain during service, continued to complain of pain and limitation following his separation from active duty service, and was subsequently diagnosed with right knee osteoarthritis in August 2004. Throughout the period on appeal, the Veteran has provided consistent lay statements of continuous problems, and the medical evidence establishes that he has a right knee disability. In addition VA regulations provide that reasonable doubt will be resolved in the Veteran's favor. 38 C.F.R. § 3.102. Therefore, the Board finds entitlement to service connection for a right knee disability is warranted. b. Left Knee After a thorough review of the evidentiary record, the Board finds the Veteran is not entitled to service connection for his claimed left knee disorder. In contrast to the evidence concerning the Veteran's right knee, the Board notes that at no time has the Veteran been diagnosed with a left knee disability. As there is no current diagnosis of a left knee disability, the criteria for service connection have not been met. As noted above, the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131; Degmetich v. Brown, 104 F.3d 1328 (1997). The current disability requirement is satisfied when a claimant "has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim," McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), or "when the record contains a recent diagnosis of disability prior to ... filing a claim for benefits based on that disability." Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The mere fact of a Veteran reporting subjective symptoms, whether knee pain, stiffness or otherwise, does not necessarily warrant a finding that he has met the current disability due to disease or injury requirement. Rather, in order for a Veteran to qualify for basic entitlement to compensation under 38 U.S.C.A. § 1110 or § 1131, the Veteran must prove existence of a disability, and one that has resulted from a disease or injury that occurred in the line of duty. See Sanchez-Benitez v. Principi, 259 F.3d 1356, 1361 (2001). In reaching the conclusion that the Veteran does not have a current left knee disability, the Board has carefully reviewed the Veteran's STRs, medical records, and lay statements. As discussed above, the Veteran did seek treatment for complaints of lower back pain, with radiating pain into his hips and knees during service. However, unlike his right knee, the Veteran never sought any treatment specifically for his left knee during his military service. The STRs do not reflect any diagnosis for a left knee disability and there are no complaints of any limitations regarding his left knee. Therefore, the Board finds there is no in-service evidence of any left knee disability, pain, or impairment. Following his separation from active duty service, the Veteran sought treatment for complaints of knee pain, which he associated with his in-service back injury. See VA Treatment Records, Dated 1985-2000. However, unlike his right knee, the Veteran has not been diagnosed with any left knee disability. Notably, an x-ray of the Veteran's left knee in July 2007 reported normal findings. See Jackson VAMC Records. Subsequent medical records continue to report normal findings. Following a physical examination in July 2011, the Veteran was diagnosed with knee "arthralgia," or joint pain. Outside of VA treatment records, the Veteran was afforded a physical examination in January 2014 in connection with his Social Security disability claim. See Medical Treatment Records, Furnished by Social Security. During this examination, the Veteran was observed to have a full range of motion across his left knee and maintained full muscle strength in his left leg. The examiner did observe crepitus in the Veteran's left knee. Following this physical examination, the physician concluded the left knee crepitus was "probably related to mild arthritis." However, the Board notes that this is not a formal diagnosis, as it was not accompanied by any diagnostic imaging reports which would confirm the presence of degenerative changes. Furthermore, the Veteran provided a self-reported history of arthritis, which is not supported by his medical records. As such, the Board finds that the Social Security examiner relied on the Veteran's self-reported history of arthritis when he reached this January 2014 conclusion. However, as the Veteran's self-reported history is not supported by the objective medical evidence, the Board finds the January 2014 diagnosis of left knee crepitus, "probably related to mild arthritis," is not entitled to any probative value. Therefore, the only diagnosis of record for the Veteran's left knee impairment is that of "arthralgia," which is given for knee joint pain. Moreover, as discussed above, the Veteran has consistently alleged his current knee pain and swelling are the result of his in-service back injury. See January 2006 Statement in Support of Claim. Lay evidence is competent to establish a diagnosis only when a lay person (1) is competent to identify the medical condition; (2) is reporting a contemporaneous medical diagnosis; or (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, unlike the Veteran's right knee, these statements are not supported by any formal left knee disability or diagnosis. Therefore, lay statements that a service event or illness caused a current disability are insufficient to establish service connection. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Additionally, the Board notes that the May 2016 VA examination and opinion provides probative evidence against service connection for the Veteran's left knee. As to a possible nexus, the VA examiner opined the Veteran has not been diagnosed with a left knee disability, other than knee joint pain or arthralgia. Additionally, the VA examiner opined the Veteran's left knee pain was less likely than not related to his military service. Specifically, the VA examiner said because this condition is associated with "normal aging" and because it developed "decades" after service, it was less likely than not related to his military service. The VA examiner further opined the gap in time between the development of this condition and his active duty service made it less likely than not that his left knee impairment was secondarily related to any other service connected disability, namely the Veteran's back arthritis. The VA examiner explained there was no medical literature which would support a finding that the Veteran's knee pain was caused or aggravated by his service connected back disability. In making this statement, the VA examiner observed the Veteran had a "fairly common anomaly" within his spine, which caused his current back pain. As this is a "fairly common anomaly," the Board finds the lack of medical literature or findings which would support the Veteran's claim for secondary service connection to be probative evidence against his claim. Therefore, the Board has reviewed all medical and lay evidence, but finds there is no probative evidence of record which establishes that the Veteran has been diagnosed with any discernable left knee disability, other than joint pain. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for service connection for a left knee disorder. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. II. Bilateral Foot Disability The Veteran seeks entitlement to service connection for a bilateral foot disability. Specifically, the Veteran alleges he has arthritis in his bilateral feet, which was caused by and/or spread from the arthritis in his back. See January 2006 Statement in Support of Claim. Additionally, the Veteran states he continues to experience pain and swelling in his feet, even after the surgery on his left foot. See June 2016 Notice of Disagreement. The Veteran further alleges he must walk very slowly in order to keep himself from falling. As to the first element of service connection, the existence of a current disability, the Board has considered the Court's holding that when determining the scope of a claim, the Board must consider the claimant's description of the claim; the symptoms the claimant describes; and the information the claimant submits or that the Secretary obtains in support of that claim. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In other words, the Board has considered all of the Veteran's bilateral foot diagnoses of record, to include any diagnoses for arthritis. A review of the Veteran's post-service medical treatment records reveals he began seeking treatment for symptoms of bilateral foot pain in January 2005. See Jackson VAMC Records. During a November 2005 physical examination, the Veteran described how he has historically experienced joint pain, primarily in his back, hips, and knees. However, at this point, the Veteran relayed that the pain and stiffness had spread into his feet. A physical examination showed the Veteran maintained a full range of motion in both his left and right foot, without any evidence or complaints of muscle weakness, swelling, or numbness. In January 2006, a radiograph of the Veteran's feet found no evidence of any fractures or dislocations. See Jackson VAMC Records. Rather, the image showed the Veteran's tarsal bones were well aligned and the joint spaces were well maintained. A January 2006 physical examination noted "slight" edema to the posterior metatarsal region of the left foot; however this was non-tender to palpation. No diagnosis was made following either the January 2006 examination or x-ray report. Subsequent medical records show the Veteran developed bony "abnormalities" within his left foot. See Jackson VAMC Records. For example, an x-ray of the Veteran's left foot in July 2011 showed the second and third toes were in a "splayed" position, which was possibly due to an "abnormal position of the second toe." This radiograph did not show any evidence of arthritis within the left foot or other degenerative changes. As to the July 2011 images of the Veteran's right foot, the radiograph produced "normal" findings, showing no evidence of no evidence of fractures, dislocations, and further reported the soft tissues were normal. The Veteran continued to complain of foot pain and swelling in both his left and right feet. In February 2012, the Veteran stated he must wear "4E" width shoes, to help with "occasional" foot welling. See Jackson VAMC Records. At this time, the Veteran reported his bilateral foot pain was due to his toes being aligned incorrectly. By September 2012, the Veteran complained of continued foot pain despite using inserts. On examination, the Veteran's bilateral second and third toes were observed to be "splayed" and the right plantar foot pad was "enlarged." However, no swelling was observed over either the left or right toes or arches. Tenderness was not elicited to palpation or manipulation of the foot. A follow-up examination and x-ray in December 2012, revealed an "abnormal position" of the left second and third toes. Following this radiograph, the Veteran was given a diagnosis of "possible metatarsalgia." The Veteran was additionally given orthotics to help alleviate the pain. In January 2014, the Veteran sought treatment for continued bilateral foot pain and swelling, despite his use of orthotics. See Jackson VAMC Records. At this time, the Veteran reported a recent episode of foot swelling which caused him to lose his bilateral toenails. A physical examination of the Veteran revealed his toenails were present bilaterally, but that the right great toenail showed evidence of regrowth. The examination found no evidence of edema or other abnormalities. Therefore, the Board finds that at various points throughout the pendency of his appeal, the Veteran has been diagnosed with a bilateral foot disorder. However, the Board finds that at no time was the Veteran diagnosed with an arthritic disorder of either his left or right foot. As there is no diagnosis of foot arthritis, the Board finds the Veteran does not meet the criteria for service connection for a chronic disease. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. As to the second and third requirements of service connection, the Board finds the competent and credible evidence does not support an in-service occurrence, aggravation, or nexus. A careful review of the Veteran's STRs does not show any evidence the Veteran ever sought treatment for or complained of any foot pain. The Veteran did report significant back pain during active duty service, and intermittently alleged pain which radiated into his hips and legs. However, a careful inspection of these records does not suggest the Veteran ever described or reported symptoms in either his left or right foot. Therefore, the Board finds no evidence that the Veteran sustained an in-service occurrence of his current bilateral foot pain and/or swelling. The Veteran's own law assertions are consistent with this finding, as he reports an onset of bilateral foot pain 10 years ago. See Jackson VAMC Records, dated January 2005; See also May 2016 VA Examination. Moreover, the Veteran's post-service medical records do not show any treatment for complaints of bilateral foot pain immediately after his separation from military service, or for several years thereafter. The first instance of treatment for the Veteran's bilateral foot pain did not occur until January 2005, which was over two decades following his separation from active duty service. The Federal Circuit Court has held that such a lengthy lapse of time between the alleged events in service and the initial manifestation of relevant symptoms after service is a factor for consideration in deciding a service-connection claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Specifically, the Board finds the length of time, between the Veteran's separation from active duty service, and his initial reports of bilateral foot pain, swelling, and limitations suggests the Veteran did not experience continuous symptoms following his separation from active duty service. As such, it follows that there is no basis to award service connection for this disorder based on chronicity in service or continuous symptoms thereafter. 38 C.F.R. § 3.303(b); Savage, 10 Vet. App. at 494-97. The remaining determination the Board must make is whether there is a causal link between the Veteran's military exposure and his current diagnosis and treatment for bilateral foot deformities. The Board notes that the record contains two medical opinions. In reviewing these opinions, the Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of evidence contained in a record; every item does not have the same probative value. The Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). First, the Board notes the Veteran was examined in connection with his application for Social Security disability in January 2014. See Medical Treatment Records, Furnished by Social Security. During this examination, the Veteran reported a history of foot swelling and pain after prolonged standing. During the physical examination, the Veteran's left great toenail was observed to have been removed, and there was evidence of re-growth. There was no evidence of swelling, cyanosis, clubbing, or edema. However, there was evidence of callus growth on the sides of the Veteran's feet. The Veteran was able to walk on his heels, and perform tandem gait walks, but refused to walk on his toes. Following this examination of the Veteran, the physician opined it was difficult to assess the etiology of the Veteran's condition, specifically, the foot swelling, without seeing it while it happens. The physician continued his assessment by stating he was unable to think of any condition that would cause the Veteran's symptoms, unless it was secondary to edema. The physician stated the Veteran's foot symptoms could alternatively be related to neuropathy, but this was less likely as the Veteran denied any symptoms of numbness. Furthermore, the physician stated the Veteran did not exhibit any "significant functional limitations" at the time of his examination. Therefore, the Board finds that this medical evaluation and opinion, amounts to a speculative etiology opinion. Notably, the physician mused as to possible causes for the Veteran's symptoms, but then provided objective reasons for why those potential causes may not be at play in the Veteran's situation. If the question of etiology cannot be determined without resorting to speculation, then it has not been proven to the level of equipoise. Chotta v. Peake, 22 Vet. App. 80, 86 (2008) (Board may not award benefits when the award would be based upon pure speculation). Second, as part of the Board prior remand, the Veteran was afforded a VA examination in May 2016, to assess the etiology and severity of his bilateral foot disorder. During this examination, the Veteran reported difficulty walking and standing for long periods. A physical examination of the left foot revealed a left second hammer toe repair/fusion, from the Veteran's surgery in August 2014. The VA examiner reported all of the Veteran's proximal phalanges were elevated, sitting on the metatarsal heads, across his left and right toes. However, all toes were flexible on examination, with the exception of the Veteran's left second toe, which was surgically fused. The VA examiner noted a March 2016 x-ray of the Veteran's foot which documented a successful fusion of the left second toe and orthopedic fixation of the head and neck of the second metatarsal. Following this examination and review of the Veteran's claims file, the VA examiner opined his bilateral foot disability was less likely than not related to his military service. Specifically, the VA examiner stated there was no evidence of an in-service injury or aggravation which would have caused the Veteran's current bilateral foot disability. The VA examiner noted the Veteran subjectively conceded this fact, as he reported his symptoms did not begin until ten years ago, which was more than two decades following his separation from active duty service. Furthermore, the VA examiner observed that although the Veteran's March 2016 e-ray showed evidence of arthritis in the left second toe, this was due proximately to the Veteran's toe fusion, and did not represent a separate diagnosis for arthritis. As to the Veteran's allegation that his bilateral foot disability is secondary to his back arthritis, the VA examiner opined there was no credible medical evidence or medical literature which would support for this claim. In making this statement, the VA examiner observed the Veteran had a "fairly common anomaly" within his spine, which caused his current back pain. As this is a common "anomaly," the Board finds the lack of medical literature or findings which would support the Veteran's claim for secondary service connection to be probative evidence against his claim. Based on his review of the Veteran's claims file, his physical examination of the Veteran, and review of all available medical literature, the VA examiner concluded it was less likely than not that the Veteran's current foot disability was caused by his military service or was aggravated by his service-connected back disability. Therefore, the Board has reviewed all the medical evidence of record, but finds no probative evidence establishes a causal link between the Veteran's military service and his current diagnosis for bilateral foot deformities. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection of his bilateral foot deformities, on either a direct, presumptive, or secondary basis. As the evidence is against the Veteran's claim, there is no reasonable doubt to resolve in his favor. Therefore, the Veteran's claim for service connection must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. III. Bilateral Hand Disability The Veteran seeks entitlement to service connection for a bilateral hand disability. Specifically, the Veteran alleges he has arthritis in his bilateral hands, which was caused by and/or spread from the arthritis in his back. See January 2006 Statement in Support of Claim. Additionally, the Veteran states he experiences a lot of stiffness, swelling, and numbness in his hands. See June 2016 Notice of Disagreement. The Veteran contends he is only capable of performing short, small tasks with his hands, before his hands swell and become painful. As to the first element of service connection, the existence of a current disability, the Board has considered the Court's holding that when determining the scope of a claim, the Board must consider the claimant's description of the claim; the symptoms the claimant describes; and the information the claimant submits or that the Secretary obtains in support of that claim. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In other words, the Board has considered all of the Veteran's bilateral hand diagnoses of record, to include any diagnoses for arthritis. A review of the Veteran's post-service medical treatment records reveals he began seeking treatment for symptoms of bilateral hand pain nearly twenty-years after his active duty service. See Jackson VAMC Records. In his June 2016 notice of disagreement, the Veteran contends that he began receiving medical treatment immediately after his separation from military service, and has continued to seek regular treatment over the past thirty years. However, these early treatment records show the Veteran only reported symptoms related to his back injury. See VA Treatment Records, Dated 1985-2000. For example, during a May 1985 examination, the Veteran reported an onset of back pain in 1981, which was non-symptomatic at the time of this examination. Subsequent treatment records reflect complaints limited to low back, hip, and knee pain. The Veteran first began reporting symptoms of bilateral hand pain in the mid-2000s. See Jackson VAMC Records. For example, during an April 2004 physical examination, the Veteran reported increased pain, particularly in his left thumb. At this time, a physical examination revealed the Veteran maintained a full range of motion across his left and right hands and fingers, with normal motor and sensory functioning. In July 2007, an x-ray of the Veteran's bilateral thumbs was taken and reported "normal" findings. The radiograph showed no evidence of any soft tissue damage or bony abnormalities. Additionally, the image showed the bilateral thumb joints were "well preserved." No diagnosis was given following this x-ray. The Veteran continued to report bilateral hand pain, with additional symptoms of swelling and stiffness. During a March 2008 physical examination, the Veteran was observed to maintain a full range of motion across his bilateral hands and wrists. The examination elicited some reports of tenderness across the radial sides of his bilateral wrists and base of his thumbs. Motor and sensory testing produced normal findings. As the Veteran continued to allege symptoms, an x-ray of the left hand was taken in August 2008. No acute fractures or dislocations were reported and degenerative changes were observed to be "minimal." Notably, no diagnosis was given following this August 2008 left hand x-ray. Treatment records dated March 2009 show the Veteran was examined following complaints of hand pain. See Jackson VAMC Records. The physical examination reported the Veteran maintained a full range of motion in his left and right hands, though some evidence of pain was observed. Motor and sensory functioning was again reported as normal. Following this examination, the VA physician wrote down his impression of the Veteran's symptoms, as "chronic pain secondary to degenerative joint disease." However, the Board notes that this is not a formal diagnosis, as there is no accompanying diagnostic evidence showing any joint space narrowing or more than "minimal" degenerative changes to the bones of his right or left hands. Therefore, this statement represents a speculative guess as to what is causing the Veteran's underlying symptoms of pain, and does not represent a formal diagnosis. In January 2014, the Veteran began reporting additional symptoms of "poor circulation" in both hands, which had developed in the previous year. See Jackson VAMC Records. A physical examination reported no signs of edema or decreased range of motion. At this time, as the Veteran's prior diagnostic examinations had been normal, the VA physician noted he questioned whether the Veteran's symptoms were attributable to arthritis or carpal tunnel syndrome. However, the physician also reported the Veteran declined to proceed with further evaluations at the time. Subsequently, the Veteran was evaluated with an electromyogram ("EMG") test. See March 2016 VA Examination. The results of this EMG were interpreted to show that the Veteran had bilateral medial neuropathy at the wrists. Notably, this diagnosis is not consistent with the Veteran's reports of bilateral hand arthritis. Furthermore, a May 2016 x-ray, reported normal findings, and was not interpreted as showing any evidence of arthritis. See March 2016 VA Examination. Outside of VA treatment records, the Veteran was afforded a physical examination in January 2014 in connection with his Social Security disability claim. See Medical Treatment Records, Furnished by Social Security. During this examination, the Veteran was observed to have a full range of motion across both his right and left hands and wrists. Grip strength testing revealed the Veteran maintained full muscle strength in both the left and right hands. The physician additionally noted there was no evidence of diminished sensation, as the Veteran's sensory functioning was "intact." Following this physical examination, the physician reported the Veteran demonstrated no "significant areas of limitations" with respect to range of motion, muscle strength, or sensation in either his right or left hand. Notably, no diagnosis was provided and no opinion provided as to what the etiology of the Veteran's hand symptoms. Therefore, the Board finds that at various points throughout the pendency of his appeal, the Veteran has been diagnosed with a bilateral hand disorder, including bilateral median neuropathy and bilateral hand arthralgia. See Jackson VAMC Records. However, the Board finds that at no time was the Veteran diagnosed with an arthritic disorder of either his left or right hand. As such, as there is no diagnosis of hand arthritis, the Board finds the Veteran does not meet the criteria for service connection for a chronic disease. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Similarly, the Board finds the length of time, between the Veteran's separation from active duty service, and his initial reports of bilateral hand pain, swelling, and limitations suggests the Veteran did not experience continuous symptoms following his separation from active duty service. As such, it follows that there is no basis to award service connection for this disorder based on chronicity in service or continuous symptoms thereafter. 38 C.F.R. § 3.303(b); Savage, 10 Vet. App. at 494-97. As to the second to the second and third requirements of service connection, the Board finds the competent and credible evidence does not support an in-service occurrence, aggravation, or nexus. A careful review of the Veteran's STRs does not show any evidence the Veteran ever sought treatment for or complained of any bilateral hand pain, numbness, or swelling. The Veteran did report significant back pain during active duty service, and intermittently reported radicular pain, which traveled down into his hips and legs. However, a careful inspection of these records does not suggest the Veteran ever described or reported symptoms in either his left or right hand. Therefore, the Board finds no evidence that the Veteran sustained an in-service occurrence of his current bilateral hand pain, numbness, or swelling. The Board notes that the Veteran has conceded a lack of in-service occurrence of aggravation of his current hand symptoms, as his lay statements describe an onset of symptoms decades after his separation from military service. See March 2006 Statement in Support of Claim. In fact, the Veteran contends he developed arthritis of his hands as a secondary condition of the arthritis in his back. See January 2006 Statement in Support of Claim. However, as discussed above, there is no evidence the Veteran was ever diagnosed with an arthritic condition in either his left or right hands. The remaining determination the Board must make is whether there is a causal link between the Veteran's military exposure and his current diagnosis and treatment for bilateral hand impairment. In this regard, the Board notes that the May 2016 VA examination and opinion provide probative evidence against service connection for the Veteran's bilateral hand disability. As part of his appeal, the Veteran was afforded a VA examination in May 2016. The VA examiner reviewed the Veteran's claims file as part of his evaluation. Of the relevant medical records, the examiner highlighted the fact that all x-rays of the Veteran's left and right hands have been normal. No x-ray within the medical record had shown any evidence of degenerative joint changes; sufficient enough to warrant a diagnosis for arthritis, and no x-ray had shown any abnormalities within the bones or soft tissues. However, the VA examiner did reference a September 2014 electromyogram ("EMG") test, which diagnosed with the Veteran with bilateral median neuropathy at the wrists. Despite this diagnosis, the VA examiner observed the Veteran continued to deny any symptoms of neuropathy, and rather asserted symptoms consistent with osteoarthritis. During this examination, the Veteran reported symptoms of bilateral hand swelling with repetitive use, stiffness, and intermittent numbness in his bilateral little and ring fingers with the ulnar aspect of the palm. The Veteran additionally reported that he experiences poor circulation in his hands and feels as though his grip strength is weaker than it was several years ago. The VA examiner conducted a physical examination of the Veteran's bilateral hands and reported he maintained full range of motion in both the left and right fingers and thumbs. No pain with range of motion testing was observed by the examiner, and no evidence of functional loss was noted with repetitive range of motion testing. Muscle strength testing revealed the Veteran maintained normal grip strength bilaterally, with no observed signs of muscle atrophy or weakness. After reviewing the Veteran's claims file and conducting a physical examination, the VA examiner opined the Veteran's bilateral hand disability was less likely than not related to his military service. The examiner additionally opined the Veteran's bilateral hand disability was less likely than not caused or aggravated by the Veteran's service connected back disability. In support of these conclusions, the examiner noted there was no evidence of an in-service occurrence or treatment for bilateral hand swelling, pain, or numbness. Additionally, the VA examiner cited to the post-service medical records which documented a slow development of the Veteran's bilateral hand pain, which the VA examiner opined is consistent with "age related" arthralgia, joint pain. The VA examiner noted that the Veteran's radiographs have thus far showed no evidence of arthritis within either the left or right hand, and thus no formal diagnosis for age related arthritis should be given. As to the Veteran's positive EMG test results, the VA examiner noted the Veteran has to this point denied any symptoms of neuropathy, and therefore this condition was not related to the Veteran's military service because of the length in time between his active service and diagnosis. The VA examiner further concluded there was no evidence in the medical literature which would prove or suggest the Veteran's back disability caused or aggravated his current hand disability. In making this statement, the VA examiner observed the Veteran had a "fairly common anomaly" within his spine, which caused his current back pain. As this is a common "anomaly," the Board finds the lack of medical literature or findings which would support the Veteran's claim for secondary service connection to be probative evidence against his claim. Therefore, the Board has reviewed all the medical evidence of record, but finds no probative evidence establishes a causal link between the Veteran's military service and his current diagnosis for bilateral hand pain and/or bilateral median neuropathy. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection of his bilateral hand impairments, on either a direct, presumptive, or secondary basis. As the evidence is against the Veteran's claim, there is no reasonable doubt to resolve in his favor. Therefore, the Veteran's claim for service connection must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. (CONTINUED ON NEXT PAGE) ORDER Service connection for the Veteran's right knee disability is granted, subject to the laws and regulations governing the award of monetary benefits. Service connection for a left knee disability is denied. Service connection for a bilateral foot disorder, to include arthritis, and to include as secondary to a service-connected disability, is denied. Service connection for a bilateral hand disorder, to include arthritis, and to include as secondary to a service-connected disability, is denied ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs