Citation Nr: 1751798 Decision Date: 11/13/17 Archive Date: 11/22/17 DOCKET NO. 04-18 651 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a low back disorder, including as due to service-connected right foot, left knee, and right ankle disabilities. 2. Entitlement to a higher initial rating for right ankle strain with degenerative joint disease (right ankle disability), currently evaluated as noncompensable from March 25, 2002 to May 9, 2004, and as 10 percent disabling from May 10, 2004. ATTORNEY FOR THE BOARD D. J. Drucker, Counsel INTRODUCTION The Veteran had active military service from June 1963 to October 1970. This case initially came to the Board of Veterans Appeals (Board) on appeal from a November 2002 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), that declined to reopen the Veteran's previously denied claim for service connection for a back disorder including as due to a service-connected right foot disability. A November 2013 rating decision granted service connection for his right ankle disability that was assigned an initial noncompensable rating from March 25, 2002 to May 9, 2002, and a 10 percent rating from May 10, 2004 A December 2008 Board decision reopened the Veteran's previously denied claim, and remanded the reopened claim at that time, and in April 2012, to the Agency of Original Jurisdiction (AOJ) for further development. In a November 2013 decision, the Board denied service connection for a low back disorder, including as due to service-connected hallux valgus of the right foot with degenerative changes and residuals of a left knee sprain. The Veteran appealed the Board's November 2013 decision to the United States Court of Appeals for Veterans Claims (Court). In a May 2015 Memorandum Decision, the Court, in pertinent part, found that the Board did not consider the impact of the Veteran's service-connected right ankle disability on his low back disorder. See 6/29/15 VBMS CAVC Decision. The Court set aside that part of the Board's decision regarding the Veteran's low back claim and remanded the matter to the Board for action consistent with the Memorandum Decision. In February 2016 and May 2017, the Board remanded the Veteran's case to the AOJ for further development. The Board notes that the Veteran was represented in his appeal by the Vietnam Veterans of America since June 2002. See 6/13/02 VBMS VA 21-22 Appointment of Veterans Serv Org. As Claimant Rep; 7/14/17 VBMS Power of Attorney (incl VA 21-22 VA 22a). In November 2015 and July 2017, he revoked that representation and elected to represent himself, pro se. See 9/23/15 VBMS Correspondence; 10/22/15 VBMS Power of Attorney (incl VA 21-22 and VA 22a); 11/2/15 VBMS Correspondence; 7/6/17 VBMS VA 21-4138 Statement in Support of Claim; 7/6/17 VBMS Third Party Correspondence. In September 2017, the Veteran referenced "issues" vacated by the Court in its June 2015 Memorandum Decision and remand of a November 2013 rating decision and appeared to address a previously considered claim of clear and unmistakable error (CUE). See 9/25/17 VBMS VA 21-4138 Statement in Support of Claim; see also 7/3/17 VBMS VA 21-4138. The Board observes that the Court's decision vacated one issue, that of service connection for a back disorder. The November 2013 rating decision effectuated the Board's November 2013 decision and granted service connection for right ankle disability that was assigned a noncompensable rating from March 25, 2002 and a 10 percent rating from May 10, 2004. A February 2016 Board decision denied the Veteran's claims of CUE in August and November 1988 Board decisions. The Board's decision is final. 38 U.S.C. § 7104 (West 2014). The matter of entitlement to an increased initial rating for right ankle disability is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDING OF FACT The weight of the probative medical and lay evidence does not establish that a low back disability, diagnosed as degenerative disc disease/degenerative joint disease of the lumbar spine, is the result of a disease or injury in active service or is proximately due or aggravated by the service-connected right foot, left knee, and right ankle disabilities. CONCLUSION OF LAW The criteria for service connection for a low back disorder, including as due to service-connected right foot, left knee, and right ankle disabilities, have not been met. 38 U.S.C. §§ 1131, 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist In letters dated in May 2002 and July 2007, the AOJ notified the Veteran of information and evidence necessary to substantiate his claim. See 38 U.S.C. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015); cert. denied (U.S. Oct. 3, 2016). VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159 (c). His service treatment records were obtained. All reasonably identified and available VA and non-VA medical records have been secured. VA medical opinions were obtained in January 2005, September 2011, May 2012, and March 2016, and the examination reports are of record. The purpose of the Board's May 2017 remand was to obtain a new medical opinion regarding the Veteran's claim for service connection for a low back disorder. There has been substantial compliance with this remand, as the Veteran was scheduled for a VA examination in July 2017 and a VA medical opinion was obtained regarding his claimed low back disorder. The July 2017 VA medical opinion is adequate for rating purposes as the claims file was reviewed, the examiner reviewed the pertinent history, provided clinical findings and diagnoses, and offered etiological opinions with rationale from which the Board can reach a fair determination. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The July 2017 opinion cured the deficiencies in the earlier opinions; hence, the Board insured that its remand instructions were complied with. There is no evidence or argument that there is additional notice or assistance that would be reasonably likely to further substantiate the claim. Based on the foregoing, the Board finds the duties to notify and assist have been met. II. Facts and Analysis Contentions The Veteran contends that he has a low back disability that had its onset during active service or, alternatively, is proximately due to his service-connected right foot, left knee, and right ankle, disabilities that caused an altered gait. See e.g., 12/6/04 VBMS VA 21-4128 Statement in Support of Claim; 3/25/02 VBMS VA 21-4138 Statement in Support of Claim; 1/13/88 VBMS Correspondence. Service connection is in effect for hallux valgus of the right foot with degenerative changes, evaluated as 10 percent disabling from October 1970 to July 1980, 30 percent disabling from July 1980 to March 1986, 20 percent disabling from February 1987 to September 1995, and as 30 percent disabling thereafter; residuals of a left knee sprain, evaluated as 10 percent disabling since March 2002; and, right ankle strain with degenerative joint disease, evaluated as noncompensable from March 2002 to May 2004, and as 10 percent disabling thereafter. Legal Criteria A veteran is entitled to compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1131, 1110; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303 (b); but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309 (a)). To establish service connection, evidence must show: "(1) the existence of a present disability; (2) 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" - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303 (a). Certain chronic diseases, such as arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service. See 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2017). For such chronic diseases under 38 C.F.R. § 3.309(a), an award of service connection can be permissible solely on the basis of lay evidence of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 ( Fed. Cir. 2013) In addition, disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service- connected disability caused by a service- connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). By regulation, VA has placed additional limitations on grants of service connection based on the basis of aggravation. 38 C.F.R. § 3.310 (b). 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, (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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). The Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). A lay person is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, but not to provide evidence as to more complex medical questions such as the origin of orthopedic pathology as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Facts Service treatment records do not reference complaints of, or treatment for, a back disorder. When examined for separation in May 1970, and again in October 1970, the Veteran denied having back trouble and a spine abnormality was not noted on examination. See 2/23/15 VBMS STR Medical (1st set), pages 87, 94; 2/23/15 VBMS STR Medical (2nd set) pages 59-60. The post service evidence includes a November 1970 rating decision that granted service connection for hallux valgus of the right foot. Medical evidence includes December 1971 and December 1974 VA orthopedic examination reports that are silent as to complaints or diagnosis of a back disorder. At a July 1981 VA examination the Veteran reported being on his feet a lot in his present work. Prolonged walking or standing or doing any squatting hurt across his forefoot with occasional aching all the way up his leg, but centered around the first metatarsal in the metatarsal phalangeal (MP) joint. On examination, he walked well without limping. A back disorder was not diagnosed. A back disorder was not discussed during a November 1985 VA orthopedic examination. A February 1987 VA orthopedic examination report notes full range of motion in both ankle joints and does not mention a back disorder. According to a February 1987 VA progress note, the Veteran complained of mid-back pain that radiated around to the right side, worse with movement. See 3/7/88 VBMS Medical Treatment Record Government Facility, page 15. The diagnosis was lumbar strain. During a May 1987 VA orthopedic examination, the Veteran complained of chronic low back pain. X-rays showed all disk spaces well maintained and no significant evidence of arthritic changes, other than some possible degenerative changes in the articular facets in the lowest lumbar segments the radiologic impression was minimal early degenerative changes in the lumbar spine although not outside the range of normal for a patient of that age. Clinical diagnoses included intermittent low back pain, essentially normal to X-ray examination, and with physical findings limited to a mild limitation of motion. A June 1987 VA rheumatology record shows that the Veteran complained of ten years of low back and ankle pain with swelling. See 7/9/87 VBMS Medical Treatment Record Government Facility, pages 1, 5. August and December 1987 follow-up evaluations indicate that he complained of back pain and the August 1987 record reveals that X-rays reportedly showed degenerative joint disease of the lumbar spine. See 12/25/88 VBMS Medical Treatment Record Government Facility, pages 3, 13, 15; 3/7/88 VBMS Medical Treatment Record Government Facility, page 21. According to a September 1987 report of a private employment physical examination performed in June 1987, the Veteran was told he had rheumatoid arthritis with involvement of both feet, shoulders and, more particularly in 1987, the low back. See 9/22/87 VBMS Medical Treatment Record Non Government Facility. His back was stiff in the morning, and there was limited motion in addition to considerable pain. Upon X-ray evaluation, no significant degenerative changes were noted in the lumbar spine, other than some slight narrowing with L5-S1. The December 1987 VA rheumatology record reflects that the Veteran's back pain was more likely due to lumbar sacral strain or to an altered gait. See 12/25/88 VBMS Medical Treatment Record Government Facility, page 3. In a January 1988 statement, the Veteran asserted that a physician told him that his back condition was connected to his foot problems. See 1/15/88 VBMS Correspondence; 1/13/88 VBMS Third Party Correspondence. During a March 1988 VA examination, the Veteran reported he began having back trouble without any definite history of injury in 1986. He claimed that his foot problems caused him to walk and use his back in a manner that caused him to have back trouble. Upon physical examination, the Veteran was advised that no pathology was demonstrated in his low back. X-rays of his lumbar spine taken at that time showed minimal osteophyte formation, otherwise, no radiographic evidence of abnormality. Radiology reports of X-rays performed privately in August 1996 and by VA in August 2002, as well as November 2003 and July 2009 private magnetic resonance image (MRI) reports, indicate degenerative disc disease in the Veteran's lumbar spine. See 12/26/96 VBMS Medical Treatment Record Non Government Facility, pages 7, 9; 8/27/02 VBMS Medical Treatment Record Government Facility, page 1; 11/24/03 VBMS Medical Treatment Record Non Government Facility, pages 3, 5; 10/16/09 VBMS Medical Treatment Record Non Government Facility, pages 3-4. In November 2003, a private orthopedist recorded the Veteran's report of having "a lot of sports related injuries in the spine area." See 6/14/04 VBMS Medical Treatment Record Non Government Facility, page 3. A January 2005 VA examination report includes the Veteran's reported history that, in 1965, he started having swelling in his ankles that still swelled, though no one told him what caused it. He also reported developing low back pain after discharge from active service. His back pain progressively worsened and he had daily pain that radiated down his right leg. Upon clinical evaluation, the diagnoses included degenerative arthritis of the lumbar spine, degenerative disc disease of the lumbar spine, and chronic sprain of the right and left ankles. The examiner opined that there were no unusual gait disturbances that would account for the Veteran's lumbar spine pain. The physician-examiner explained that the Veteran's lumbar spine pain was of a degenerative nature and a product of the degenerative aging process; therefore, it was less likely than not that his lumbar spine was secondary to his (service-connected) right big toe injury and degenerative changes. The examiner also stated that the Veteran's ankle examination was essentially normal and there was no intrinsic disease of the ankles that would be related to the Veteran's left knee impairment. A February 2005 rating decision granted service connection for residuals of a left knee sprain. In a September 2011 addendum, a VA physician assistant opined that it was unlikely that the Veteran's current normal ankle examination was anatomically or physiologically related to any spine or foot disorder. The clinician noted that mild degenerative changes found on X-ray studies should be considered normal for a male who was 66 years old. A May 2012 VA examiner diagnosed multilevel degenerative disc disease of the Veteran's lumbar spine with associated chronic lumbar pain. The Veteran stated that he began having lumbar pain after a fall in 1966 when he was seen for his left knee injury. His lumbar pain started at that time, and he had lumbar spine pain on a daily basis since 1966 that gradually increased since his 1970 discharge from service. Despite the pain, the Veteran worked as a mail clerk for over 28 years, since discharge from service, until his retirement from the postal service in 2007. Upon clinical examination, the examiner opined that it was less likely as not that the Veteran's current lumbar condition was caused or the result of active military service. The examiner explained that there was no evidence of a chronic or recurrent lumbar condition in service and the Veteran's separation examination noted no problems with his back. The Veteran was able to work for over 20 years on his feet with the post office without serious back problems. Further, the examiner opined it was less likely as not that the Veteran's current lumbar condition was caused or aggravated by his service-connected right foot disorder. The examiner reasoned that there was no medical authority that supported the contention that chronic hallux valgus with reparative surgery was causative to the development of multilevel degenerative disc disease of the lumbar spine. The Veteran's degenerative disease was the result of many years of wear on the disc mechanism, and was found in the majority of patients the Veteran's age. Additionally, the examiner opined that it was less likely as not that the Veteran's current lumbar condition was caused or aggravated by the Veteran's service-connected left knee. The examiner explained that there was no medical authority to support the contention and the Veteran's gait was non antalgic. The examiner did not consider the impact of the Veteran's right ankle disability on the low back disorder. A May 2012 private MRI report of the Veteran's lumbar spine showed lower lumbar spine degenerative disc and facet disease resulting in central canal and neural foraminal stenosis. See 6/6/12 VBMS Medical Treatment Record Non Government Facility, page 1. The November 2013 rating decision granted service connection for a right ankle disability. Records dated between July 2015 and February 2016 describe the Veteran's chiropractic treatment for lumbar spine pain. See 4/25/16 VBMS Medical Treatment Record Non Government Facility. The March 2016 VA examiner noted the Veteran's history of lumbar strain diagnosed in the 1960s and lumbar degenerative disc disease and degenerative joint disease diagnosed in the 2000s. The Veteran reported that he began having problems with his lower back almost immediately during service from 1963 to 1970, when he was stationed on board ship and was required to perform heavy physical labor/duties. After service discharge in 1970, the Veteran worked for the US Postal Service, from which he retired in 2007. The Veteran stated that his lower back gradually worsened in the past four or five decades, and he currently had daily lower back pain, with intermittent bilateral lower extremity radicular symptoms. The Veteran ambulated with a cane for lower back and extremity stability and comfort. The examiner observed that the Veteran was noted to have a positive rheumatoid factor blood test at the Shreveport VA in the 1970s and that no recent rheumatologic markers were drawn. X-rays of the Veteran's lumbar spine taken on examination day revealed multi-level prominent anterior osteophytes, moderate degenerative disc disease at L3-4 with multi-level mild degenerative disc disease throughout the remainder of his lumbar spine, and moderate to severe facet degeneration in the lower lumbar spine. The examiner commented that results of laboratory studies taken that day showed that the only significantly elevated rheumatologic inflammatory marker was a non-specific sedimentation rate. The examiner opined that it was less likely as not that the Veteran's current lower back disability was etiologically related to active military service, or caused or aggravated by any of his service-connected disabilities, either singly or combined. The examiner reasoned that, first, as stated in prior VA examination reports by other providers, the service treatment records contain no documentation whatsoever of any lower back issues that the examiner could locate. Second, the Veteran was service-connected for right foot hallus valgus, left knee sprain, and right ankle strain with degenerative joint disease. The examiner observed that these three lower extremity conditions were all quite mild in severity; X-rays showed only mild degenerative joint disease of the right great toe and right ankle, and no pathology of the left knee at all. Therefore, it was rather unlikely that these relatively minor issues would cause or aggravate a relatively significant lower back degenerative disc disease/degenerative joint disease condition, as was clearly noted on various imaging studies including currently. Finally, that day's rheumatologic markers revealed no current evidence of rheumatoid arthritis at all. In its May 2017 remand, the Board found the examiner's rationale at odds with the evidence of record, including that the Veteran's right foot disability was rated 30 percent disabling that was the highest available schedular rating and denotes a severe foot disability. See e.g. 38 C.F.R. § 4.71a, Diagnostic Code 5271-5003 (2018). Private medical records, dated from September to November 2016, discuss the Veteran's treatment for a left knee lateral meniscus tear that required arthroscopic surgery in November 2016. See 7/14/17 VBMS Medical Treatment Record Non Government Facility, pages 5, 12. When initially seen in October 2016, his gait and station were normal. Id. at 1. The July 2017 VA examiner noted that the Veteran denied any specific injury or trauma to his back before, during, or after, military service. The Veteran reported that he first complained of back pain in the 1980s at the Shreveport VA. He had intermittent sharp pain across his lower back that occurred after walking more than 10 steps or driving an extended time, with occasional numbness or tingling of both legs for which he has chiropractic treatment and took pain medication. The Veteran ambulated with a cane due to his knee. The examiner opined that the Veteran's low back disorder was less likely than not (less than a 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner explained that a review of the available electronic medical records was silent regarding a back condition while the Veteran was in service and within one year of his discharge from active service. The first indication of possible symptomatic thoracolumbar degenerative disc disease/degenerative joint disease was in 2002 at the age of 58 (NB: an apparent reference to indication in VA medical records), and lumbar strain was first diagnosed in 2012. The examiner further opined that the Veteran's back disorder was less likely than not proximately due to or the result of the Veteran's service-connected disabilities or aggravated (permanently worsened by them). The examiner noted that the Veteran was service-connected for right foot hallux valgus status/post-surgery with degenerative joint disease, left knee sprain, and right ankle strain with degenerative joint disease. According to the examiner, the first indication of possible symptomatic thoracolumbar degenerative disc disease/degenerative joint disease was in 2002 at when the Veteran was 58 years old. The majority of peer-reviewed medical literature states that the most common cause of lumbar disc disease and lumbar degenerative joint disease was related to the aging process and obesity. The examiner knew of no credible peer-reviewed medical literature that supported the contention that right foot hallux valgus status/post-surgery with degenerative joint disease, left knee sprain, and right ankle strain with degenerative joint disease, or combination of these conditions to have direct causative effect in the development of degenerative disc disease/degenerative joint disease of the thoracolumbar spine. The examiner reiterated that the first indication of possible symptomatic thoracolumbar degenerative disc disease/degenerative joint disease was in 2002 when the Veteran was 58 years old. The examiner observed that the Veteran reported that he had one epidural treatment in 2005 and chiropractic treatment for the last three years and had not necessitated more invasive treatments. Therefore, the examiner concluded that it was less likely than not that a current low back disorder was aggravated (permanently worsened beyond the natural progression) by any of the service-connected disabilities, or the combined effects of the service-connected disabilities. Finally, the examiner stated that he agreed with the previous three VA examiners' opinions and rationales. The examiner also did not know of peer-reviewed credible medical literature that supported the contention that right foot hallux valgus status post-surgery with degenerative joint disease, left knee sprain, and right ankle strain with degenerative joint disease have direct causative effect on the development of degenerative disc disease/degenerative joint disease of the thoracolumbar spine. The majority of peer-reviewed medical literature states that the most common cause of lumbar disc disease and lumbar degenerative joint disease is related to aging process and obesity. Analysis While arthritis is among the listed chronic diseases, and a continuity of symptomatology could establish a link between that disease and service, the first documented evidence of degenerative disc disease of the lumbar spine is dated in 1996, 26 years after the Veteran's discharge. See Walker v. Shinseki, 708 F.3d at 1331. In so noting, the Board recognizes that the mere absence of medical records is not dispositive as to the question of continuity; the lay evidence must be considered as well. See Buchanan v. Nicholson, 451 F.3d at1335. If, however, it is determined based on reliable evidence, that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In this case, the lay evidence has been inconsistent as to onset of back symptoms. Here, when examined for separation in May 1970, the Veteran specifically denied a history of back problems and physical examination of his spine was negative. Post-service, the Veteran underwent VA examinations of his service-connected right foot in December 1971, December 1974, July 1981, and February 1987. The Board finds it reasonable to conclude that, if the Veteran was experiencing ongoing back problems, he would have reported these problems at the same time as other complaints. Additionally, while the Veteran told the May 2012 and March 2016 examiners that he had experienced symptoms since the 1960s, this is inconsistent with his express denial of such symptoms at the time of separation from service in 1970. Moreover, in other post-service reports of his medical history he indicated a much later onset of low back pain. For example, in a June 1987 clinical record discussed above, he reported only a 10-year history of back problems, placing the onset many years after service. A March 1988 record notes an onset of back symptoms in 1986. As these reports were given in the course of treatment, as opposed to during an examination for the purpose of determining entitlement to benefits, they are deemed highly probative. Moreover, even at the January 2005 VA examination, the Veteran again reported an onset of symptoms following service. Overall, then, the weight of the evidence here fails to support continuity of low back symptoms since the time of active service. Absent a continuity of symptoms, the Veteran would not be competent to say that degenerative disc disease and degenerative joint disease of the lumbar spine first demonstrated decades after service was caused by a disease or injury in service or service-connected disability. See Buchanan v. Nicholson, 451 F.3d at 1331. Lay testimony is competent if it is limited to matters that the lay person actually observed and is within the realm of the witness's personal knowledge. See 38 C.F.R. § 3.159 (a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). Given the above, continuity of symptomatology is not established, either by the clinical evidence or the lay statements of record. Moreover, the weight of the medical evidence is against a finding of nexus to service or to another service-connected disability. Indeed, the July 2017 opinion from the VA examiner is the most probative evidence of record on the question of a nexus. It shows that the claims file was extensively reviewed and the Veteran's reports considered. The examiner's opinion is entirely consistent with that of the January 2005, May 2012, and March 2016 examiners. Since the VA examiner's opinion was based on a review of the pertinent medical history, and was supported by sound rationale, it provides compelling evidence against the appellant's claim. In reaching this conclusion, the Board acknowledges the examiner's erroneous statement that lumbar strain was first diagnosed in 2012, when records show it was diagnosed in 1987. Nevertheless, the Board emphasizes that the VA examiner provided a valid medical analysis to the significant facts of this case in reaching his conclusions. In other words, the VA examiner did not only provide data and conclusions, but also provided a clear and reasoned analysis that the Court has held is where most of the probative value of a medical opinion comes is derived. See Nieves-Rodriguez v. Peake, 22 Vet App at 295. The Veteran believes that his claimed disability is related to active service or his service-connected right foot, left knee, or right ankle, disabilities, but this opinion lacks probative value, because he lacks the medical expertise needed to attribute his low back disability to active service as opposed to the other possible causes. The VA examiner was well qualified to assess the causes of the low back disability in the Veteran's system and provided extensive reasons for his opinions. There is no competent and credible lay or medical opinion or evidence to refute the July 2017 VA examiner's opinion. The preponderance of the evidence is, thus, against a finding that a low back disorder is related to the Veteran's active service including service-connected right foot, left knee, and right ankle disabilities. In sum, the weight of the objective and credible medical and lay evidence is against the claim for service connection for a low back disorder, including as due to service-connected right foot, left knee, and right ankle disabilities. Reasonable doubt does not arise, and the claim must be denied. Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001). ORDER Entitlement to service connection for a low back disorder, including as due to service-connected right foot, left knee, and right ankle disabilities, is denied. REMAND In December 2013, the Veteran disagreed with the disability ratings assigned in the November 2013 rating decision that granted service connection for his right ankle disability and assigned the noncompensable rating from March 25, 2002 and the 10 percent rating from May 10, 2004. See 12/24/13 VBMS Third Party Correspondence. The Veteran's statement is a timely notice of disagreement and the issue must be remanded, so that the AOJ can issue a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: Issue a statement of the case as to the matter of an initial compensable rating for right ankle disability from March 25, 2002 to May 9, 2004, and a rating higher than 10 percent thereafter. If, and only if, the Veteran timely perfects an appeal as to the matter, should the claim be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.§§ 5109B, 7112 (West 2014). ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs