Citation Nr: 1754029 Decision Date: 11/27/17 Archive Date: 12/07/17 DOCKET NO. 08-25 622 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Sioux Falls, South Dakota THE ISSUES 1. Entitlement to service connection for peripheral neuropathy of the right lower extremity (claimed as numbness of the left hip, leg, and foot), to include as secondary to service-connected fractures of the right superior and inferior pubic rami with minimal deformity. 2. Entitlement to service connection for peripheral neuropathy of the left lower extremity (claimed as numbness of the right leg and foot), to include as secondary to service-connected fractures of the right superior and inferior pubic rami with minimal deformity. 3. Entitlement to service connection for a right elbow disability. 4. Entitlement to higher ratings for fractures of the right superior and inferior pubic rami with minimal deformity, initially rated as noncompensable (0 percent disabling) prior to November 6, 2007 and as 10 percent disabling from that date. 5. Entitlement to compensation under 38 U.S.C.A. § 1151 for degenerative joint disease with resection arthroplasty of the right wrist (claimed as a right hand and thumb disability). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD B. Elwood, Counsel INTRODUCTION The Veteran served on active duty from April 1962 to January 1963. This appeal to the Board of Veterans' Appeals (Board) arose from March 2008, November 2008, and October 2014 rating decisions. In the March 2008 decision, the RO, inter alia, denied the Veteran's petition to reopen a claim for service connection for right elbow arthritis and granted service connection for fractures of the right superior and inferior pubic rami with minimal deformity and assigned an initial 0 percent (noncompensable) disability rating, from November 6, 2007. Later that month, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in August 2008 and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veteran's Appeals) later that month. In the November 2008 rating decision, the RO, inter alia, denied the Veteran's claims for service connection for numbness of the right leg and foot and numbness of the left hip, leg, and foot. In February 2009, the Veteran filed an NOD. An SOC was issued in June 2009 and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veteran's Appeals) later that month. In the October 2014 rating decision, the RO, inter alia, denied the Veteran's claim for compensation under 38 U.S.C.A. § 1151 for degenerative joint disease with resection arthroplasty of the right wrist (claimed as a right hand and thumb disability). Later that month, the Veteran filed an NOD. An SOC was issued in November 2014 and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veteran's Appeals) in December 2014. For purposes of clarity, a brief recitation of pertinent portions of the factual and procedural history of these claims follows. In an August 2008 decision, a Decision Review Officer (DRO) assigned an effective date of January 5, 1963 for the award of service connection and a noncompensable (0 percent) rating for fractures of the right superior and inferior pubic rami with minimal deformity on the basis of clear and unmistakable error (CUE). In a November 2009 decision, a DRO assigned an initial 10 percent disability rating for fractures of the right superior and inferior pubic rami with minimal deformity, from November 6, 2007. In February 2012, the Board, inter alia, granted the Veteran's petition to reopen the claim of service connection for right elbow arthritis and remanded the underlying claim as well as the claims of service connection for peripheral neuropathy of the right and left lower extremities and the appeal for a higher initial rating for right superior and inferior pubic rami with minimal deformity for further development. After accomplishing the requested action, the agency of original jurisdiction (AOJ) continued to deny the service connection and higher rating matters on appeal (as reflected in an October 2012 supplemental SOC (SSOC)) and returned these matters to the Board for further appellate consideration. In March 2015, the Board remanded all matters listed on the title page for a requested Board hearing before a Veterans Law Judge (VLJ). In September 2015, the Veteran testified during a Board video-conference hearing before the undersigned VLJ; a copy of the transcript is of record. In July 2016, the Board again remanded all matters on appeal to the AOJ for further development. After completing the requested development, the AOJ continued to deny the matters on appeal (as reflected in a January 2017 SSOC) and returned these matters to the Board for further appellate consideration. This appeal has been advanced on the Board's docket, pursuant to 38 U.S.C.A. § 7107 (a)(2) (West 2012) and 38 C.F.R. § 20.900 (c) (2017). The Board previously characterized the claim for service connection for a right elbow disability as a specific claim of service connection for right elbow arthritis. The Board has now expanded the claim, as reflected on the title page, to encompass any right elbow disorder(s) reasonably raised by the record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). As a final preliminary matter, the Board notes that, during the pendency of this appeal, in a July 2015 rating decision, the RO reduced the disability ratings for arthritic changes of the cervical spine and left shoulder impingement syndrome. Later that month, the Veteran filed an NOD. An SOC was issued in August 2015, the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veteran's Appeals) in February 2016, and a VA Form 8, Certification of Appeal, pertaining to the cervical spine and left shoulder issues was completed in December 2016. Regardless, the cervical spine and left shoulder issues cannot yet be addressed by the Board because there is a pending request for a Board hearing. These matters may be the subject of a future Board decision, if necessary. While the Veteran previously had a paper claims file, this appeal is now fully being processed utilizing the paperless, electronic Veterans Benefits Management System (VBMS) and Virtual VA (Legacy Content Manager) claims processing systems. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim herein decided have been accomplished. 2. No lower extremity neuropathy or right elbow disability was shown during active service or for years thereafter; there is no credible evidence of continuity of lower extremity neurological symptomatology in the years since service; and the most persuasive medical opinion evidence of record weighs against findings that there exists a medical relationship, or nexus, between the later diagnosed disabilities and service, or that the diagnosed neuropathy affecting both lower extremities caused or has been aggravated by the service-connected fractures of the right superior and inferior pubic rami with minimal deformity. 3. The only competent, probative medical opinion to address the question of whether the Veteran has additional right hand/wrist disability resulting from VA treatment weighs against the claim. 4. Since the January 5, 1963 effective date of the award of service connection, the Veteran's fractures of the right superior and inferior pubic rami with minimal deformity have been manifested by pain, tenderness, discomfort, stiffness, weakness, instability, and heat; right hip motion has been limited to at most 82 degrees of flexion, 15 degrees of extension, 22 degrees of abduction, 25 degrees of adduction, 60 degrees of external rotation, and 40 degrees of internal rotation; there has been no additional loss of motion due to such factors as pain, weakness, lack of endurance, incoordination, or fatigability during flare ups or with repeated use over time; there has been no hip ankylosis, flail joint, or impairment of the femur. 5. During the time period in question, there is competent and credible evidence of actual right hip pain during the time period. plausibly resulting in some functional loss. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral neuropathy of the right lower extremity, to include as secondary to service-connected fractures of the right superior and inferior pubic rami with minimal deformity, are not met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 2. The criteria for service connection for peripheral neuropathy of the left t lower extremity, to include as secondary to service-connected fractures of the right superior and inferior pubic rami with minimal deformity, are not met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 3. The criteria for service connection for a right elbow disability are not met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 4. The criteria for compensation, pursuant to the provisions of 38 U.S.C.A. § 1151, for degenerative joint disease with resection arthroplasty of the right wrist (claimed as a right hand and thumb disability) as a result of VA treatment, are not met. 38 U.S.C.A. §§ 1151, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.358, 3.361 (2017). 5. Resolving all reasonable doubt in the Veteran's favor, the criteria for an initial 10 percent rating for right superior and inferior pubic rami with minimal deformity, from January 5, 1963 to November 6, 2007, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5003, 5014, 5250-5255 (2017). 6. A rating in excess of 10 percent for right superior and inferior pubic rami with minimal deformity is denied. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5003, 5014, 5250-5255 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2017). With respect to the appeal for higher initial ratings for fractures of the right superior and inferior pubic rami with minimal deformity, the appeal arose from the Veteran's disagreement with the initial ratings assigned after the award of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim of service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (2003). The United States Court of Appeals for Veterans Claims (Court) has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as initial rating) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128 (2008). Notably, however, after the Veteran's disagreement with the initial ratings assigned for the fractures of the right superior and inferior pubic rami with minimal deformity, the criteria for higher ratings for hip disability were set forth in the August 2008 SOC. As for the remaining matters being decided herein, after a complete or substantially complete application for benefits is received, notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Pelegrini v. Principi, 18 Vet. App. 112 (2004) and Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ. Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, letters dated in October 2007, September 2008, February 2012, and June 2014 provided notice regarding what information and evidence was needed to substantiate the claims for service connection for peripheral neuropathy of the left and right lower extremities and a right elbow disability (on both a direct and secondary basis) and for compensation under 38 U.S.C.A. § 1151 for degenerative joint disease with resection arthroplasty of the right wrist, as well as what information and evidence must be submitted by the claimant, and what information and evidence would be obtained by VA. The letters also provided information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations. Hence, these letters meet Pelegrini's and Dingness/Hartman's content of notice requirements. The March 2008, November 2008, and October 2014 rating decisions reflect the RO's initial adjudication of the claims. The Board acknowledges that the February 2012 letter (which provided notice regarding what information and evidence was needed to substantiate a claim for service connection on a secondary basis) was not issued prior to the November 2008 rating decision which denied service connection for peripheral neuropathy of the left and right lower extremities. However, the claims for service connection for peripheral neuropathy of the left and right lower extremities were thereafter readjudicated in the October 2012 SSOC. Accordingly, any timing deficiency has been appropriately cured. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The record also reflects that, consistent with applicable duty-to-assist provisions, VA has made reasonable efforts to develop the Veteran's claims, to include obtaining or assisting in obtaining all relevant records and other evidence pertinent to the matters herein decided. Pertinent evidence associated with the claims file consists of the Veteran's service treatment records, VA treatment records, private medical records, and the reports of VA examinations which were conducted to obtain information as to the nature and etiology of the claimed bilateral peripheral neuropathy of the lower extremities, right elbow disability, and right hand/wrist disability and as to the severity of the service-connected fractures of the right superior and inferior pubic rami with minimal deformity. Also of record and considered in connection with the appeal are the transcript of the September 2015 Board hearing, along with various statements submitted by the Veteran and her representative, on her behalf. The Board finds that no further development on any claim herein decided, prior to appellate consideration, is required. As for the September 2015 Board hearing, it is noted that, during the hearing, the Veteran appeared, along with her authorized representative, and provided testimony on the 1151 matter herein decided. At that time, the undersigned VLJ identified all of the issues on appeal, to include the matters herein decided, but also explained that the Veteran had only indicated that she wished to have a hearing which addressed the 1151 matter on appeal; with respect to the 1151 issue, information was solicited regarding the nature and history of the Veteran's claimed disability, why it was believed her claimed disability was related to VA treatment, and the treatment received for her claimed disability. Although the undersigned did not explicitly suggest the submission of any specific, additional evidence in connection with the 1151 claim, , on these facts, such omission was harmless, as the hearing testimony revealed the need for additional development, which was sought on subsequent remand. Thus, the hearing was legally sufficient. See 38 C.F.R. § 3.103 (c)(2) (2017); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board also finds that, relative to the claims herein decided, there has been substantial compliance with the Board's February 2012 and July 2016 remand directives. See Dyment v. West¸ 13 Vet. App. 141, 146-47 (1999); see also D'Aries v. Peake, 22 Vet. App. 97, 105-106 (2008). Pertinent to the matters decided herein, the Board directed that the AOJ request that the Veteran identify any outstanding treatment records and complete the appropriate authorization so as to allow VA to obtain any outstanding private treatment records, obtain any outstanding VA treatment records and private treatment records identified by the Veteran, afford the Veteran VA examinations to obtain information as to the nature and etiology of her claimed right wrist/hand disability and as to the severity of the service-connected fractures of the right superior and inferior pubic rami with minimal deformity, obtain medical opinions as to the etiology of the claimed bilateral lower extremity neuropathy, right elbow disability, and right wrist/hand disability, and obtain a retrospective opinion regarding the severity of the Veteran's fractures of the right superior and inferior pubic rami with minimal deformity since the effective date of service connection. VA neurological, elbow, hand/wrist, and hip/thigh examinations were conducted in March 2012 and November 2016, medical opinions were provided pertaining to the etiology of the claimed lower extremity neurological, right elbow, and right hand/wrist disabilities and as to the severity of the service-connected fractures of the right superior and inferior pubic rami with minimal deformity since the effective date of service connection, and all outstanding VA treatment records have been obtained and associated with the claims file. Also, in February 2016 letters, the AOJ requested that the Veteran identify any outstanding treatment records and complete the appropriate authorization so as to allow VA to obtain any outstanding private treatment records. The Veteran did not identify or submit any outstanding treatment records. VA is only required to seek pertinent records that are adequately identified and for which necessary releases are furnished. 38 U.S.C.A. § 5103A (b); 38 C.F.R. §§ 3.159 (c)(1)(i), (c)(2)(i) (requiring a claimant to cooperate fully with VA's efforts to obtain federal and non-federal records); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (the duty to assist is not always a one-way street). Thus, VA has no further duty to attempt to obtain any additional treatment records. In summary, the duties imposed by the VCAA have been considered and satisfied. 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 any of the matters herein decided. As such, the Veteran is not prejudiced by the Board proceeding to a decision on these claims, at this juncture. See Mayfield v. Nicholson, 20 Vet. App.539, 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). II. Analysis A. Service Connection Claims Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). See also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); (Fed. Cir. 2006). The determination as to whether elements are met is based on an analysis of all the evidence of record and the evaluation of its competency, credibility and probative value. See Baldwin v. West, 13 Vet. App., 8 (1999). Service connection may also be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires: (1) competent evidence (a medical diagnosis) of current disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either (a) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). If a veteran serves 90 days or more of active, continuous service during a period of war, or during peacetime service after December 31, 1946, and certain chronic diseases, including organic diseases of the nervous system, become manifest to a compensable degree within a prescribed period post service (one year for organic diseases of the nervous system), service connection for the disease may be established on a presumptive basis, notwithstanding that there is no in-service record of the disorder. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. This presumption may be rebutted by affirmative evidence to the contrary. 38 U.S.C.A. § 1113; 38 C.F.R. § 3.307 (d). With chronic disease shown as such in service (or within the presumptive period under 38 C.F.R. § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. 38 C.F.R. § 3.303 (b). Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic, or when the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that the provisions of 38 C.F.R. § 3.303 (b) pertaining to the award of service connection on the basis of continuity of symptomatology apply only to chronic diseases as defined in 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As noted, organic diseases of the nervous system are among the diseases listed in 38 C.F.R. § 3.309 (a). Laypersons, such as the Veteran, are competent to report on matters observed or within his or her personal knowledge, to include the occurrence of injury, and as to the nature, onset, and continuity of symptoms experienced or observed. See 38 C.F.R. § 3.159 (a)(2); Charles v. Principi, 16 Vet. App. 370 (2002); Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board, however, retains the discretion to determine the credibility and probative value of all evidence of record, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that 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. In the present case, the Veteran contends that she has a current bilateral neurological disability of the lower extremities and a current right elbow disability which are related to injuries that she sustained in connection with a motor vehicle accident in service. In the alternative, she contends that the current bilateral neurological disability of the lower extremities is related to her service-connected fractures of the right superior and inferior pubic rami with minimal deformity. The reports of March 2012 VA neurological and elbow examinations indicate that the Veteran has been diagnosed as having bilateral idiopathic peripheral sensory neuropathy of the lower extremities and right lateral epicondylitis. Thus, current bilateral lower extremity neurological and right elbow disabilities have been demonstrated. The remaining question with respect to each claim is whether the diagnosed disability had its onset during service or is otherwise medically related to in-service injury or disease or a service-connected disability, as alleged. As discussed below, however, the Board finds that the record presents no basis for an award of service connection for the current bilateral lower extremity neuropathy and right elbow disability. The Veteran has not specifically reported a continuity of lower extremity neurological or right elbow symptomatology in the years since service. She has, however, reported general joint pain since her in-service motor vehicle accident and her representative contended in a November 2014 statement that the Veteran claimed a continuity of neurological and right elbow symptomatology in the years since the in-service accident. The Board points out that the Veteran has already been awarded service connection for residuals of a right mid humerus fracture. Regardless, she is competent to report the symptoms and history of her claimed disabilities (including a continuity of symptomatology) and the Board has reason to challenge the credibility of reports concerning a continuity of right elbow symptoms in the years since service. Despite competent and credible reports of right elbow symptoms in the years since service, however, an award of service connection for the Veteran's current right elbow disability solely based on evidence of a continuity of symptomatology is not available to the Veteran because the current disability is not among the chronic conditions listed in 38 C.F.R. § 3.309 (a). Service connection on the basis of a continuity of symptomatology (in lieu of a medical opinion), alone , may only be granted if a claimed disability is among this list of chronic conditions. See Walker, 708 F.3d at 1338. Moreover, as explained below, the most persuasive medical opinion evidence of record weighs against finding that there exists a medical relationship, or nexus, between the currently diagnosed right elbow disability and service. Service treatment records reflect that the Veteran presented for treatment in May 1962 for a 1 year history of a "pinch[ed] nerve" in the low back, which started when she was making a bed. Aside from back symptoms, examination revealed no neurologic involvement. Deep tendon reflexes were sluggish, but not asymmetric, and the Veteran was diagnosed as having a back strain with "no evidence [of] nerve involvement." In September 1962, the Veteran was involved in a motor vehicle accident in which she suffered a concussion, a fracture of the right humerus, and lacerations over the left eye. She was treated for one week at the University Hospital in Augusta, Georgia and was subsequently admitted to a military treatment facility with her right arm splinted and the lacerations healed. She was placed on bedrest and x-rays of the right arm revealed a fracture of the middle third of the right humerus. There was no apparent radial nerve injury, there was good function of the fingers, and circulation was normal. She was diagnosed as having a simple fracture of the middle third of the right humerus with no major artery or nerve involvement, concussion of the brain, and a healed lacerated wound of the left forehead with no major artery or nerve involvement. She was discharged to light duty in a hanging cast in October 1962. A November 1962 service treatment record reflects that the Veteran reinjured her arm again in an accident, but that she was not experiencing any real pain. She was not wearing a sling and her cast was removed for examination. She was referred for physical therapy for active motion of the elbow and service treatment records dated in December 1962 indicate that she had almost full range of motion of the right arm. The report of the Veteran's December 1962 separation examination notes that she had an old fracture of the right humerus and that she lacked 10 degrees of extension at the elbow, but that she was fit for full duty. Her separation examination was otherwise normal. There is no evidence of any further complaints of or treatment for lower extremity neurological or right elbow problems in the Veteran's service treatment records. The Veteran has provided information and statements which are inconsistent with any reports alluding to a continuity of lower extremity neurological symptomatology. For instance, the Veteran's representative has contended that her lower extremity neurological symptoms have continuously existed in the years since service. However, the Veteran reported during an October 2007 VA primary care evaluation that she experienced numbness in her feet which started in her left foot and gradually spread to both feet and up the legs. It was "over several months that this ha[d] gotten gradually worse" and she initially thought that the tingling was the result of a foot injury where she broke her foot. Also, she reported during an October 2009 VA spine examination that she was experiencing a "new onset"of feelings of numbness and burning on the sides and bottoms of her feet and toes and foot coldness. She first noted such symptoms several months prior to the October 2009 examination and she felt that "it was a rather sudden onset." Such information is inconsistent with any report of continuous lower extremity neurological symptoms in the years since service. Given the absence of any evidence of complaints of or treatment for lower extremity neurological problems in the Veteran's service treatment records, the fact that there was no evidence of any neurological abnormalities during the December 1962 separation examination, and the information and statements provided by the Veteran that are inconsistent with a continuity of symptomatology, the Board concludes that, as to continuity of lower extremity neurological symptoms since service, any such reports are deemed not credible. Thus, neither the clinical record nor the lay statements of record establish a continuity of lower extremity neurological symptomatology in this case. Furthermore, the Board notes that, with respect to the medical etiology opinions of record, the preponderance of the competent, probative opinions weigh against the claims. In December 1996, the examiner who conducted an April 1995 VA examination indicated that the Veteran had reported during the examination that she had generalized aches of varying severity in most joints (and especially those for which the examination was requested, which included the right elbow) since her motor vehicle accident in 1962. The examiner acknowledged that some arthritis may develop in many people of the Veteran's age, that trauma is considered a contributory cause of arthritic changes, and that it was not possible to assign a percentage of arthritis due to trauma and a percentage due to aging. The examiner opined that the Veteran's arthritis was likely to be a direct consequence of the car accident in 1962, with age being a minor contributory factor. In an October 1997 letter, J.K.M. Easton, M.D. reported that the Veteran's medical records had been reviewed. Dr. Easton explained, in pertinent part, that the Veteran was involved in a motor vehicle accident in September 1962 and suffered a concussion, a facial laceration, and a fractured right humerus. She was initially treated at a university hospital, but was transferred to the hospital at Fort Gordon. During her hospitalization she complained of right hip pain, dizziness, and headaches, but there was no mention of any other pain or physical inability. She was dismissed to the barracks in October 1962 with a hanging cast on her right arm and was considered fit for light duty. She was discharged from service in January 1963 and the report of her separation examination noted limited right elbow extension, without any other physical problems. After service, the Veteran worked as a waitress, in a hospital kitchen and a clothing store, and as a silversmith and casino cashier. Most of these jobs involved some stress to her neck, arms, hands, back, and legs. She was examined in April 1995 by Dr. Jentes, during which there was limitation of right elbow motion and a diagnosis of fibromyalgia was provided. Bone x-rays conducted in April 1995 revealed minimal degenerative changes of the elbows. Dr. Easton concluded that the Veteran had performed work which involved stress to her arms, that x-rays of the elbows did not show more than "minimal degenerative changes" which would be compatible with her work history, and that her elbow arthritis was more likely related to her activities after service than the accident or any stress that occurred during service. Thus, it was not likely ("not at least as likely as not") that the arthritis was caused by or a result of the motor vehicle accident in September 1962. The examiner who conducted the October 2009 VA spine examination opined that the Veteran's bilateral peripheral neuropathy was not likely ("less likely as not") caused by or a result of her pelvic fractures. She reasoned that EMGs and lumbar MRI were without evidence of nerve compression or abnormality and that there was no anatomical correlation between the pelvis and the nerves involved. Also, the disability was presenting 45 years after the initial injury. The physician assistant who conducted the March 2012 VA neurological and elbow examinations explained that the Veteran's claimed right elbow disability was identified as mild episodic lateral epicondylitis, as opposed to arthritis, based on normal right elbow x-rays in 2007 and 2012 which did not confirm the presence of arthritic changes. Rather, the Veteran had episodic symptoms/flares consistent with mild lateral epicondylitis of the right elbow. The examiner opined that it was not likely ("less likely than not") that the Veteran's right elbow disability originated during service, occurred within the one year period immediately following service, or was otherwise attributable to service (to include the vehicle accident in September 1962 with resultant right mid-shaft humerus fracture). The examiner reasoned that examination of the Veteran's right elbow was normal other than for mild lateral epicondylitis that had intermittent flares. X-ray findings and active range of motion were normal during the March 2012 examination and x-rays of the elbow and elbow flexion were normal in 2007. Elbow extension during the March 2012 examination was improved from an examination in 2007. The Veteran's service-connected right-humeral fracture had healed per x-rays as early as the 1980s. The examiner further reasoned that residuals of a humeral fracture related to the elbow would not be medically expected long-term sequelae, particularly in the case of the Veteran who remained active and working until approximately 70 years of age. She had many jobs that required significant use of her hands and arms for most of her post-military adult life. For instance, she worked as a waitress, cashier, silversmith, and receptionist. If the Veteran had a right elbow disability dating back to service or to her humeral fracture, one would expect her to have difficulty engaging in these types of employment. All of the aforementioned jobs add cumulative stress on the arms/forearms that can result in repetitive use injuries (particularly in the dominant arm (the right elbow in this case)) to produce a lateral epicondylitis that has a waxing and waning pattern. Complaints of upper extremity pain in the Veteran's right arm were not found in the claims file until the 1980s and her initial complaints were of right shoulder pain with a history of dislocations. As for the bilateral peripheral neuropathy of the lower extremities, the March 2012 examiner opined that the disability was not likely ("less likely than not") aggravated by the Veteran's service-connected old healed fractures of the right superior and inferior pubic rami with minimal deformity. The examiner explained that the Veteran's service-connected injury occurred in 1962 and that she was discharged from the hospital less than 3 weeks after the accident fully ambulatory to light duty. A review of the medical evidence revealed that symptoms of bilateral foot numbness were not reported until 40 years later. The symptoms had always been reported to be bilateral, involving her feet in a stocking distribution. Her injury was unilateral, involving the right superior and inferior pubic rami and portions of the pelvis. There were no findings of peripheral neuropathy or numbness of the lower extremities mentioned in the Veteran's service treatment records or within the first years post military separation. The formerly fractured, now healed, portions of the pelvis are not anatomically in a position to have neurologic pathways damaged that could create numbness or neuropathy in a distribution that the Veteran had been describing over the past several years. She had normal EMG studies in 2008 and a lumbar MRI in 2009 with no findings of nerve root impingement or disc herniation. In 2008, x-rays revealed old well-healed fractures with only minimal deformity involving the right superior and inferior pubic rami. In October 2016, the VA physician assistant who conducted the March 2012 VA examinations re-reviewed the Veteran's claims file and provided opinions as to the etiology of her claimed right elbow disability and lower extremity neuropathy. With respect to the right elbow, the physician assistant opined that it was not likely ("less likely than not") that the Veteran's right elbow epicondylitis (or any right elbow condition, to include arthritis) had its onset during service or in the year immediately following service. This opinion was based on the fact that there was no medical documentation found to indicate that the elbow symptoms were present during the Veteran's service, during her hospitalization due to a motor vehicle accident, at the time of her military separation, or during the year immediately following service. She reported diffuse episodic arm aching (not localized or mentioned to include the right elbow) at the time of a 1964 VA examination and there was less than 5 degrees of lack of right elbow extension. This right elbow extension was not reported to be objectively or subjectively painful or to exhibit weakness, fatigue, lack of coordination, or lack of endurance with movement. At subsequent examinations, the right elbow range of motion was shown to have normal extension with complaints of pain, including during the 2012 examination. Moreover, although x-rays of multiple joints (including the bilateral elbows) which were performed in 1995 were interpreted by the independent medical examiner (IME) as showing minimal hypertrophic changes, the IME also stated that the minimal x-ray changes were "more than likely due to the various types of activities/employments [the Veteran] has maintained," (including a waitress, working in a hospital kitchen and clothing store, as a casino cashier, and as a silversmith) which caused stress on her arms. The IME stated that "the arthritis in elbows . . . is more likely related to [the Veteran's] activities after service than to the accident or any stress during her time in service." There is no evidence of record to establish that elbow arthritis was manifested to a compensable degree within one year of service. The x-rays that the IME reviewed were taken over 30 years after the Veteran's discharge from service. Additionally, the most recent imaging evidence from both 2007 and 2012 (right elbow x-rays) showed a normal right elbow with no degenerative change or pathology. The Veteran had no neurologic deficits documented at any time due to a right elbow condition. She had normal and symmetrical muscle tone/strength of the upper extremities, as stated by a non-VA neurologist in 2015. The physician assistant also opined that it was not likely ("less likely than not") that the Veteran's right elbow epicondylitis, or any right elbow disability, was otherwise medically related to service, to include right arm injury or right elbow/arm symptoms therein. The physician assistant reasoned that the Veteran's statements of record did not support any specific chronic right elbow condition until she had been out of service for over 30 years. In 2007, right elbow pain was mentioned during a July 2007 VA nursing evaluation, at which time the Veteran reported to her provider that the right elbow was a service-connected condition (this was in error, because the right elbow was not service-connected). Subsequently, x-rays taken of the right elbow in 2007 were normal. There was no continuity of right elbow pain previously described in the medical records. In a 2012 interview, the Veteran provided a vague description of right elbow pain and stated that "it hurts like arthritis," in spite of a lack of findings of arthritis on both 2007 and 2012 x-rays of the right elbow. Right elbow epicondylitis with tenderness at the lateral epicondyle is a common condition with repetitive movement, especially supination/pronation of the elbow, as in many of the jobs that the Veteran has held over the years which involve repetitive forearm movement (including bookkeeping, working as a waitress, working in a kitchen, and working as a silversmith). Additionally, the Veteran had a post-service diagnosis of fibromyalgia, which can also present with tender points/trigger points over the epicondylar region of the elbow. As for the bilateral peripheral neuropathy of the lower extremities, the physician assistant opined that the Veteran's disability (diagnosed as idiopathic bilateral lower extremity sensory peripheral neuropathy involving the lower 1/3 of the legs/feet) did not likely ("less likely than not") have its onset in service or in the year immediately following service. The physician assistant reasoned that there were no complaints of foot/lower leg numbness during active duty. A neurologic exam at the time of separation from service was normal and the 1964 VA examination revealed no neurological complaints of numbness. The 1964 examiner noted that the Veteran had no neurological involvement after her in-service motor vehicle accident or at the time of the November 1964 examination. Several physicians (including the Veteran's neurologists and physiatrists) had thought that the complaints of numbness, dysesthesias, and paresthesias of the feet in a stocking distribution were possibly related to taking medication (topiramate) for headaches. The diagnosis of idiopathic peripheral neuropathy is not uncommon. The Veteran did not report that the numbness of the lower portions of her lower extremities began in service or in the years shortly after service. Rather, her history showed that her complaints of a neuropathic nature began over 30 years after service. Therefore, no temporal relationship could be made to associate this condition with her brief period of service. The physician assistant also opined that it was not likely ("less likely than not") that the Veteran's bilateral idiopathic lower extremity neuropathy was medically related to service, to include the motor vehicle accident in service or any neurological symptoms noted during service. This opinion was based on the fact that there was no chronicity of pathology or complaints of numbness in the bilateral, symmetrical stocking type distribution noted during service, including in hospital and clinic notes in service. The orthopedic doctor who conducted the May 1962 in-service examination noted that there were bilateral sluggish, but symmetric reflexes. However, this clinical finding is a normal human physiologic variant and does not imply pathology "in [absence] of otherwise normal exam." The Veteran's diagnosis during the May 1962 examination was a back strain with no evidence of neurologic involvement. During her hospitalization, there was no mention of any numbness/paresthesias in the feet or legs. During the initial VA examination in November 1964, the Veteran did not report, and there were no examination findings, of any numbness or tingling in the lower extremities below the knee, and there were no findings consistent with any stocking distribution neuropathy. Although the November 1964 examiner also mentioned generalized sluggish reflexes, there is no indication that this was felt to be asymmetric or that it indicated any pathology. Human physiologic limits in reflex testing can show variance in reflexes from 0 (reflex absent) to 3+ (severely hyperreflexive, or suggestive of clonus by some examiners). Mild reflex changes from examination to examination can be entirely normal for a patient. This variance can be due to normal human fluctuation and/or an examiner's variance in position of the patient and the examiner's observation of brief, subjective testing. The medical evidence did not support any complaints of stocking type numbness until it was mentioned as worsening in 2005 forward, which was over 40 years after the Veteran's separation from service. The complaints were worked up with laboratory tests, brain imaging, and EMGs. The EMG testing was negative in 2008, but was positive in 2014 and showed some sensory neuropathy of the distal lower extremities. The physician assistant further explained that multiple neurologists and physiatrists had assessed the Veteran and that no pathological basis was identified as the source of her neurological condition. Hypotheses included the use of topiramate for chronic migraines, vitamin B12 malabsorption, and idiopathic neuropathy. The most recent conclusion was idiopathic peripheral neuropathy and the diagnosis was best identified as idiopathic bilateral lower extremity sensory peripheral neuropathy involving the lower 1/3 of the legs/feet (peroneal nerve and sural nerve bilaterally). This diagnosis was based on the most recent EMG in 2014 and was consistent with the Veteran's reported symptoms. Some treatment providers who had assessed the Veteran's deep tendon reflexes, including neurologists and primary care providers, had found them to be diminished. However, "the general clinical findings support bilateral symmetrical decreased lower extremity were seen in a small number of veteran's exams during various years." The normal EMG study in 2008 and the 2014 EMG showing a symmetrical sensory decrease to the bilateral lower extremity sensory nerves of the ankles/feet did not relate to the subjective examination findings of an intermittent decrease in reflexes. There has never been any central lesion of brain/radicular findings for the lumbosacral spine identified that could affect motor function and could possibly affect lower extremity deep tendon reflexes. The intermittent, symmetrical variances in lower extremity deep tendon reflexes are most likely a normal physiologic variant for the Veteran, whose gait and station continues to remain normal. It is known from studies (which were specifically referenced by the physician assistant) that rating reflexes has very little reproducibility from one examiner to another (or even for a single examiner from one examination to another). The Board finds that the December 1996 and October 1997 opinions are of limited probative value. Specifically, the December 1996 opinion only references arthritis in general and it is unclear as to the extent to which it is specifically applicable to the Veteran's right elbow complaints, as opposed to her reported symptoms involving multiple other joints. In addition, both the December 1996 and the October 1997 opinions only pertain to arthritis, whereas the Veteran's current right elbow disability does not include arthritis. Rather, the right elbow disability that has been present during the current claim period (i.e., since approximately August 2007) has been identified as right lateral epicondylitis. The March 2012 elbow opinion is also of limited probative value because it is, at least in part, based upon an inaccurate history. Although the examiner reasoned that complaints of right arm pain were not evident in the claims file until the 1980s, the November 1964 VA examination report reflects that the Veteran reported right arm aching and that examination revealed slight (less than 5 degree) limitation of right elbow extension. Hence, the March 2012 elbow opinion is partially based on an inaccurate history and is therefore of little probative value. See Monzingo v. Shinseki, 26 Vet.App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely") (citing Reonal v. Brown, 5 Vet.App. 458, 461 (1993)). By contrast, the October 2009 opinion, March 2012 neuropathy opinion, and October 2016 opinions were based upon examinations of the Veteran and a complete review of her medical records and reported history, are accompanied by specific rationales that are consistent with the evidence of record, acknowledge and discuss the findings of right arm pain/slight limitation of elbow extension and sluggish reflexes in service and shortly following service, address whether the Veteran's current bilateral lower extremity neuropathy and right elbow disability had their onset in service or in the year immediately following service or are otherwise medically-related to service, and address whether the current neuropathy was caused or aggravated by the service-connected fractures of the right superior and inferior pubic rami with minimal deformity. Thus, these opinions are adequate and entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The Board thus finds that the October 2009 opinion, March 2012 neuropathy opinion, and October 2016 opinions outweigh the December 1996 opinion, October 1997 opinion, and March 2012 elbow opinion, and constitute the only competent, probative opinions to address the matters central to adjudication of the claims on appeal. Notably, there is no other medical evidence or opinion indicating that the Veteran's current bilateral peripheral neuropathy of the lower extremities or right elbow disability are related to service or that the bilateral peripheral neuropathy of the lower extremities was caused or aggravated by a service-connected disability, and neither the Veteran nor her representative has identified or alluded to the existence of any such evidence or opinion. Furthermore, while the Veteran has expressed her own belief that her claimed disabilities are related to the injuries sustained in her motor vehicle accident in service or are associated with her service-connected fractures of the right superior and inferior pubic rami with minimal deformity, such assertions do not provide persuasive support for the claims. The e Veteran is certainly competent to attest to matters within his own personal knowledge, such as those observed or experienced (see, e.g., Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005)), and may opine as etiology of some simple disabilities, such as those observable or otherwise perceived through the senses (see Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (Lance, J., concurring)). However, resolution of a not complex medical matter, such as the etiology of her peripheral neuropathy of the right and left lower extremities and right elbow disability involves internal processes extending beyond an immediately observable cause-and-effect relationship, and the Veteran is no shown to have the medical training and expertise to competently opine on such a matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007) (a layperson may be competent to attest to a broken leg, but not to diagnose cancer). and a motor vehicle accident in service or between her current peripheral neuropathy of the right and eft lower extremities and her service-connected fractures of the right superior and inferior pubic rami with minimal deformity, as resolution of such questions. As the question of nexus with respect to these claims may not be competently addressed by lay evidence, the lay statements of record do not constitute competent, probative evidence on this point. Id. See also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009);). Under these circumstances, the Board must conclude that the record does not support a finding that the Veteran's currently diagnosed bilateral peripheral neuropathy of the lower extremities or right elbow disability had their onset in service or within the first post-service year following her January 1963 separation from service, or are otherwise medically related to service, or that the bilateral peripheral neuropathy of the lower extremities was caused or aggravated by the service-connected fractures of the right superior and inferior pubic rami with minimal deformity. For all the foregoing reasons, each claim under consideration must be denied. In reaching the decision to deny each claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, the benefit-of-the-doubt doctrine is not applicable, and, hence, not helpful in this instance. See 38 U.S.C.A. § 5107 (b) (West 2012);); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990. B. 1151 Claim The Veteran filed her claim for compensation under the provisions of 38 U.S.C.A § 1151 in June 2014. The version of 38 U.S.C.A. § 1151 applicable to claims filed on or after October 1, 1997 provides that compensation shall be awarded for a qualifying additional disability or a qualifying death of a veteran in the same manner as if such additional disability or death were service-connected. 38 U.S.C.A. § 1151. A disability or death is a qualifying additional disability or qualifying death if the disability or death was not the result of a veteran's willful misconduct and (1) the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the Secretary, either by a VA (Department) employee or in a Department facility as defined in 38 U.S.C.A. § 1701 (3)(A), and (2) the proximate cause of the disability or death was (a) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or (b) an event not reasonably foreseeable. Id. The implementing regulation applicable to section 1151 claims received on or after October 1, 1997, is 38 C.F.R. § 3.361, which provides that, in order to determine whether a veteran has an additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy program upon which the claim is based to the veteran's condition after such care, treatment, examination, services, or program has stopped. VA considers each involved body part or system separately. 38 C.F.R. § 3.361 (b). To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in a veteran's additional disability or death. Merely showing that a veteran received care, treatment, or examination and that the veteran has an additional disability or died does not establish cause. 38 C.F.R. § 3.361 (c)(1). Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361 (c)(2). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability or death, it must be shown that the hospital care, medical or surgical treatment, or examination caused the veteran's additional disability or death as explained in 38 C.F.R. § 3.361 (c) and that (1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (2) VA furnished the hospital care, medical or surgical treatment, or examination without the veteran's or, in appropriate cases, the veteran's representative's informed consent. 38 C.F.R. § 3.361 (d)(1). Whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361 (d)(2). In this case, the Veteran claims that she has additional right wrist/hand disability that is the result of improper VA treatment following a September 2013 resection arthroplasty of the right wrist with forearm tendon graft. Specifically, she contends that she developed additional right wrist/hand disability due to her use of a splint on the right wrist that was designed for the left wrist. VA treatment records dated from February to September 2013 reveal that the Veteran had a ganglion (a bulging, fluid-filled mass) on the lateral side of the right wrist and that she had experienced right hand/wrist pain and discomfort for a "couple of years" that was dull, continuous, and aching in nature, was aggravated by bumping the wrist or lying it on the table, and resulted in decreased function and physical activity. Examination revealed no obvious degenerative changes of the metacarpotrapezial joint, but there was pain in the carpal bones and exquisite tenderness to palpation of the scaphotrapezium joint. X-rays revealed evidence of degenerative arthritis between the scaphoid and the trapezium bones. She was scheduled for a resection arthroplasty with forearm tendon graft and a pre-operative diagnosis of right wrist pain with arthritis was provided. Prior to the resection arthroplasty with forearm tendon graft, the Veteran signed a September 2013 VA "Consent for Clinical Treatment/Procedure" form. This document informed her that the reason for the surgery was basilar joint arthritis that caused pain at the base of the thumb, provided a brief description of the procedure, and informed her of the known risks and side effects of the procedure. These risks/side effects included, but were not limited to, continued loosening of the joint; damage to nerves (including temporary or permanent pain, numbness, or weakness); incomplete recovery of normal function; incomplete relief of pain; pain, numbness, swelling, weakness, or scarring where the tissue was cut; painful scars that may limit function or range of motion; stiffness or decreased range of motion; weakness; new or worsening arthritis; and recurrence of the injury. The Veteran was also informed that the procedure may not cure or relieve her condition or symptoms and that they may come back and/or worsen. VA treatment records dated from September 2013 to January 2014 reflect that the Veteran was doing well following surgery and that she was initially placed in a sling and cast. She experienced some deep aching on the radial side of the wrist, but her pain was well controlled and she felt that her procedure was healing well. Her sutures were removed without complication and there was no edema, erythema, or ecchymosis about any of the incision sites. Her cast was removed at the VA Medical Center in Fort Meade, South Dakota (VAMC Ft. Meade) in October 2013 and examination at that time revealed that the range of motion of her wrist was limited and that there was quite a bit of pain and tenderness over the radial side of the wrist. There was good radial nerve function, good apposition of the digits, and decent strength between the thumb and index finger. A diagnosis of a well-healing right wrist arthroplasty was provided. The Veteran was given a thumb spica splint, was advised to wear the splint for a month, and was scheduled for occupational therapy. She subsequently contacted VA and indicated that she had been given a splint for the right wrist that was designed for the left wrist. As a result, she experienced hand pain while wearing the splint and was unable to wear it as instructed. She was nonetheless instructed to continue wearing the splint during sleeping hours. The Veteran continued to attend occupational therapy, during which she initially reported that she experienced soreness/achiness in the thumb at rest, that the pain increased with thumb motion, and that there was constant numbness/burning along the volar forearm, dorsal thumb, dorsal index, and thenar area of the thumb. As a result, she used her left hand for eating and was not using her right hand for activities of daily living. She was given a correct splint and indicated that it fit better. After continued occupational therapy, she began using her right hand to complete more activities at home and discontinued use of the splint, but she continued to experience some right thumb pain and soreness which radiated up the radial forearm. Examinations of the right hand/wrist in November and December 2013 revealed edema underneath the postsurgical wound and into the right wrist, tenderness to palpation over the postsurgical site and into the palm of the hand, pain with resistance, some decreased strength due to pain, and a positive grind test. There was no erythema or ecchymosis, the tissue was healed, the ranges of motion of the wrist and fingers were appropriate, there was good apposition to all digits, and distal circulation was intact. She again started using a thumb spica splint on the right hand and was advised to stop any type of exercise or range of motion therapy until the inflammation subsided. She was diagnosed as having a well-healing resection arthroplasty of the right wrist that was "just healing slowly", a well-healed resection arthroplasty of the thumb with persistent pain, and radioschaphoid arthritis of the right wrist, status post right wrist resection arthroplasty. A March 2014 VA physical therapy note, a June 2014 statement from the Veteran's sister, a June 2014 statement from the Veteran, an October 2014 "Notice of Disagreement" form (VA Form 21-0958), the Veteran's testimony during the September 2015 hearing, VA treatment records dated from February to September 2016, and the report of a November 2016 VA wrist examination indicate that the Veteran continued to experience right hand/wrist pain and weakness and that she was limited in her ability to perform various activities of daily living. She used medication and a hot wax treatment to treat her symptoms. An examination revealed that the ranges of right wrist motion were decreased, that there was pain and tenderness to palpation over the first carpalmetacarpal joint, and that right hand grip strength was slightly weak. X-rays of the right wrist revealed likely degenerative or posttraumatic changes of the first carpal metacarpal articulation. The Veteran was diagnosed as having degenerative joint disease of the right first metacarpal joint, status post resection arthroplasty using palmaris longus tendon. The examiner who conducted a September 2014 VA examination opined that the Veteran's right thumb disability was not likely ("less than likely") the result of surgery and/or inappropriate or inadequate medical care since the Veteran's September 2013 surgery and that her complaints of difficulty with the right thumb were reasonably foreseeable, since persistence or worsening of symptoms following surgery is discussed in the preoperative consent. The examiner explained that the Veteran was clearly advised of the potential for no improvement, new or worsening arthritis, and failure of the procedure prior to undergoing the procedure. A review of the operative note revealed that there were no surgical complications. The Veteran was seen regularly in the postoperative period and given more than adequate consults, including a hand therapist for care. Her pain did improve from a 7 to a 3-4 and her strength improved markedly during her therapy in the post-operative period. She had been issued a thumb spica splint prior to her surgical intervention, which she could have used when the left thumb spica splint was causing her pain. The physician who conducted the November 2016 VA examination opined that it was not likely ("less likely than not") that the Veteran's degenerative joint disease with resection arthroplasty of the right wrist was caused by the September 2013 resection arthroplasty of the right wrist with forearm tendon graft and subsequent post-operative treatment at VAMC Ft. Meade. The examiner explained that the September 2013 surgery was done in treatment of the degenerative joint disease of the wrist and that the surgery did not cause the degenerative joint disease. The November 2016 examiner also concluded that the Veteran had not been diagnosed as having any additional right wrist/hand disabilities since June 2014 (i.e., during the current claim period) and that her contention that she incurred additional right wrist/hand disability due to the use of a left wrist splint on her right wrist following the September 2013 surgery was not supported by her treatment records, current symptoms, and examination findings. The examiner reasoned that a review of orthopedic treatment notes dated from June 2014 showed multiple entries regarding shoulder, foot, and other problems. There was only one clinic note that mentioned the right wrist in terms of pain and weakness that was treated conservatively. These symptoms were residuals of the degenerative joint disease that was treated surgically in 2013, and they are expected consequences of the surgery. Therefore, they do not represent an additional disability. VA treatment records dated since June 2014 did not show that the Veteran was having significant issues with her wrist, since there was only one treatment record discussing the wrist, as compared to multiple records discussing unrelated orthopedic issues that have been ongoing problems. The symptoms reported during the November 2016 examination were not outside the range of what is expected for the Veteran's degenerative joint disease of the wrist with surgical treatment. The examiner further explained that the VA treatment records dated in late 2013, following the episode where the Veteran was given a splint for the left wrist in October 2013, showed that she had no issues following this episode, as reflected in October and November 2013 treatment records. It was not until 5 weeks after getting the splint and several weeks after discontinuing its use that the Veteran reported more pain. The increased pain that occurred in late November 2013 was a natural consequence of her starting to use the wrist more at that time and it was not a remote consequence of the splint given to her in October 2013. The Veteran's current history and examination did not indicate the presence of any additional disability beyond what was expected following the resection arthroplasty for first carpometacarpal degenerative joint disease. The September 2014 opinion is of minimal probative value because the examiner did not identify what, if any, additional right wrist/hand disability the Veteran has experienced during the claim period. In addition, the opinion that was provided addresses whether the VA medical and surgical treatment was the actual cause of the Veteran's claimed disability (i.e., that the "right thumb condition" is not likely the result of the September 2013 surgery or post-operative care), but the rationale that accompanies the opinion explains why the VA medical and surgical care was not the proximate cause of the claimed disability (i.e., why the proximate cause of the claimed disability was not carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA or an event not reasonably foreseeable). See 38 U.S.C.A. § 1151 (West 2012); 38 C.F.R. § 3.361 (2015). In other words, there is no rationale that directly explains why the Veteran's claimed right wrist/hand disability was not actually caused by the September 2013 surgery and the post-operative care. Hence, the September 2014 opinion is of little, if any, probative value. By contrast, the November 2016 opinion is based upon an examination of the Veteran, a review of cited medical literature, and a complete review of the Veteran's medical records and reported history, is accompanied by a specific rationale that is consistent with the evidence of record, and addresses whether the Veteran developed any additional right hand/wrist disability as a result of the September 2013 surgery and post-operative treatment (to include the use of an incorrect splint). Thus, the November 2016 opinion is adequate and entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Significantly, there is no other medical evidence or opinion indicating that the Veteran developed any additional right hand/wrist disability as a result of her September 2013 surgery and post-operative treatment and neither the Veteran nor her representative has identified or alluded to the existence of any such evidence or opinion. While the Veteran has expressed her belief that she developed additional right hand/wrist disability as a result of her surgery and post-operative treatment, such assertions do not provide persuasive support for the claim. While she is certainly competent to describe matters within her personal knowledge, as a layperson not shown to have appropriate medical training and expertise, she is not competent to render a probative opinion on a complex medical matter, such as whether additional right hand/wrist disability developed as a result of the September 2013 surgery and the use of an incorrect splint during the postoperative period (particularly when she had already been experiencing right hand/wrist symptoms prior to the surgery), as resolution of such question involves internal processes extending beyond an immediately observable cause-and-effect relationship. As the question of whether additional disability developed in this case may not be competently addressed by lay evidence, the lay statements of record do not constitute competent, probative evidence on this point. See,Davidson, 581 F.3d at 1313; Jandreau, 492 F.3d at 1372. Under these circumstances, the Board finds that the claim of entitlement to compensation benefits, pursuant to the provisions of 38 U.S.C.A. § 1151, for degenerative joint disease with resection arthroplasty of the right wrist (claimed as a right hand and thumb disability) as a result of VA treatment must be denied. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against this claim, that doctrine is not applicable in this instance. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. C. Higher Ratings Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). When the question for consideration is entitlement to a higher initial rating assigned following a grant of service connection, evaluation of the medical evidence since the effective date of the award and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The ratings for the Veteran's right superior and inferior pubic rami with minimal deformity have been assigned under 38 C.F.R. § 4.71a, DCs 5251-5014. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27 (2017). Here, the use of DCs 5251-5014 reflects that the Veteran's disability is partially described as osteomalacia and that the rating assigned is based on limitation of motion of the thigh under DC 5251. DC 5014 refers to osteomalacia, which is to be rated on limitation of motion of affected parts, as arthritis, degenerative. See 38 C.F.R. § 4.71a, DC 5014. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, DC 5003. Under DC 5251, a 10 percent rating is warranted for limitation of extension of the thigh to 5 degrees. This is the maximum schedular rating under DC 5251. 38 C.F.R. § 4.71a, DC 5251. Under DC 5252, the following ratings apply to limitation of flexion of the thigh: a 10 percent rating is warranted when it is limited to 45 degrees; a 20 percent rating is warranted when it is limited to 30 degrees; a 30 percent rating is warranted when it is limited to 20 degrees; and a 40 percent rating is warranted when it is limited to 10 degrees. 38 C.F.R. § 4.71a , DC 5252. Also, DC 5253 provides a 10 percent disability rating where there is limitation of adduction of the thigh such that the legs cannot be crossed or there is limitation of rotation such that it is not possible to toe out more than 15 degrees. A 20 percent rating requires limitation of abduction with motion lost beyond 10 degrees. 38 C.F.R. § 4.71a, DC 5253. For rating purposes, normal ranges of hip motion are 0 to 125 degrees of flexion and 0 to 45 degrees of abduction. 38 C.F.R. § 4.71, Plate II (2017). The Board notes that when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2017); DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Further, in claims for higher ratings for musculoskeletal disabilities, where a veteran has a noncompensable rating and complains of pain on motion, the veteran may be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). In Petitti v. McDonald, 27 Vet. App. 415 (2015), the Court held that under 38 C.F.R. § 4.59, "the trigger for a minimum disability rating is an actually painful, unstable, or malaligned joint," and it explained that 38 C.F.R. § 4.59 speaks to both painful motion of joints and actually painful joints. Id. at 425. Moreover, the Court held that 38 C.F.R. § 4.59 does not require "objective" evidence, but can be satisfied with lay and other non-medical evidence. Id. at 429. The provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton, supra; Id. In this case, an October 1962 service treatment record, medical records dated from July 1987 to June 1994, and a June 1994 statement from the Veteran (VA Form 21-4138) document reports of right hip pain, pubic bone pain at the lower quadrant which radiated to the left low back, suprapubic to bilateral groin discomfort, and pelvic heaviness. The Veteran was diagnosed as having musculoskeletal discomfort. The Veteran reported during an April 1995 VA examination and in a November 1995 statement that she experienced aching in most joints which was aggravated by any activity. For instance, pressure over the trochanter areas caused pain, the hip joints were very sore, and the pain went down into the legs. An examination of the hips revealed mild arthritic changes and decreased ranges of motion. Specifically, right hip flexion and abduction were to 82 degrees and 42 degrees, respectively and left hip flexion and abduction were to 88 degrees and 40 degrees, respectively. X-rays revealed mild degenerative changes involving the bony structures of the hip joints and a deformity involving the right inferior ischial pubic ramus which was probably related to an old healed fracture. The examiner who conducted the April 1995 examination also noted that the Veteran's muscle soreness and tenderness was believed to be due to fibromyalgia. Also, the examiner indicated in a December 1996 statement that the Veteran reported that she had experienced generalized aches and pains of varying severity in most joints (especially those for which the April 1995 examination was requested, including the hips) since her accident in service in 1962. In an October 1997 letter, J.K.M. Easton, M.D. reported that the Veteran was involved in a motor vehicle accident in service in September 1962 and that while hospitalized following the accident she complained of pain in her right hip. There was no evidence that the hip pain persisted or was a factor in the Veteran's recovery or subsequent medical problems. The old pubic ramus injury that was evident in the 1995 x-rays may well have occurred at the time of the motor vehicle accident, but there was no evidence of ongoing disability related to the injury. The Veteran reported in an October 2007 letter and during a February 2008 VA examination that she experienced occasional sharp pains in the pelvic area, constant hip pain, constant hip stiffness (especially in the morning), and difficulty walking. The hip pain was 7/10 in intensity, there was hip weakness and instability and her hips would occasionally (1-2 times per month) give out when she went to stand, the hip would feel hot, and she occasionally fell due to her hip instability. There was no swelling, redness, or locking. She also had fibromyalgia and this played a part in her pain. There were no flare ups of symptoms, the Veteran did not use any assistive devices, she had not undergone any hip surgery, there were no episodes of dislocation or recurrent subluxation, and there was no history of inflammatory arthritis or gout. She had heated seats put in her car to help with her back, hips, and buttocks. Also, her hip symptoms impacted her occupation in that she experienced difficulty lifting and carrying files and required the assistance of others. At home, she was unable to move furniture, performed less housework, and was unable to walk on a treadmill. Examination of the hips revealed no heat, redness, or swelling. The examiner did not get a sense of any real motion problems with the right hip and Patrick testing on the right was negative. The Veteran had good strength bilaterally and no sensory loss was noted. The right hip was not warm or tender to palpation, but the Veteran reported pain down into the thigh muscle. The examiner opined that this was more of a fibromyalgia-type pain. There was no effusion, instability, or weakness, the Veteran was able to walk without difficulty and with no limp, there was no limitation when standing or walking, there were no calluses on the Veteran's feet, and there was no breakdown or unusual footwear. Also, there was no ankylosis, the leg lengths were equal bilaterally, and there was no prosthesis in either hip joint. The results of range of motion testing of the right hip were recorded as flexion to 93 degrees active and 102 degrees passive, abduction to 22 degrees active and 32 degrees passive, and extension to 15 degrees both active and passive. The ranges of left hip motion were recorded as flexion to 93 degrees active and 104 degrees passive, abduction to 24 degrees active and 30 degrees passive, and extension to 15 degrees both active and passive. The Veteran terminated most of the passive range of motion testing due to subjective pain. After 5 repetitions of adduction/abduction maneuvers there was no objective evidence of pain, wincing, grimacing, fatigue, weakness, lack of endurance, or incoordination. The examiner noted that based on the above, he would have to resort to mere speculation to determine whether any of these factors have caused additional functional loss during a flare up. Regardless, the Veteran reported that she did not experience any flare ups and that her pain remained at the same level at all times. X-rays revealed old healed fractures of the right superior and inferior pubic rami with only minimal deformity, radiographically normal hips for age, prominent sclerosis at lumbosacral junction (likely related to underlying degenerative changes, but not entirely conclusive), and incidental old calcified injection granulomata in the buttocks bilaterally. The report of an October 2009 VA examination indicates that the Veteran experienced intermittent deep pain in the pelvic area which was located in the inguinal region. The pain was 7-8/10 in intensity, was a sharp spasm in nature, occurred 2 to 3 times per month with no warning, lasted for approximately 5 minutes at a time, and did not have any triggers. When the pain occurred the Veteran would stop what she was doing, bend over, and apply pressure to the area until the pain resolved. There was also an aching in the same area which was 1-3/10 intensity, occurred 1 to 2 times per week without warning, and did not have any alleviating factors. There was no weakness, stiffness, swelling, warmth, erythema, or drainage. The Veteran did not experience any instability and there was no history of any falls or unstable gait. She did not experience any specific flare ups of symptoms. Rather, the symptoms would come and go on a sporadic basis and remained at a low level in her consciousness. She did not use any assistive devices, there were no constitutional symptoms of bone disease, there were no occupational effects because the Veteran was no longer employed, and she was able to perform her basic activities of daily living without problems. Examination of the pelvis revealed that there was tenderness to palpation over the pelvic symphysis pubis and along the pelvic bones anteriorly bilaterally. There was no warmth, erythema, or swelling. The Veteran's gait was normal and there were no callosities or unusual shoe wear patterns. Flexion and extension of the hips was within the normal range bilaterally, but abduction was slightly limited bilaterally. There was objective evidence of discomfort in terms of grimacing, but there was no guarding. The Veteran was diagnosed as having fractures of the pelvis with minimal deformity and pain on palpation. VA treatment records dated from August 2013 to June 2014 document reports of pelvic/groin/right hip discomfort and pain. The pain was 5-7/10 in intensity, continuous and aching in nature, and aggravated by walking. The pain resulted in decreased function, quality of life, and physical activity. Medications did not provide much symptom relief, but the pain was minimal if the Veteran was sitting. Examinations revealed that the Veteran got up and down from the examination table and chair a little bit slowly and stiffly, but that her gait was normal after she started moving. There was point tenderness over the trochanteric bursa of the right hip, but the hip was not red or swollen. X-rays revealed mild degenerative changes of the hips and bony demineralization. The Veteran was diagnosed as having probable right trochanteric bursitis. The Veteran reported during a November 2016 VA hip and thigh examination that when she was discharged from service her pelvic fractures seemed to be all right. She gave birth to a son in 1964 and did not have any problems during the pregnancy or vaginal delivery on account of the pelvic fractures. She briefly worked in a sewing factory and did not experience any problems at work due to her hip or pelvis. She subsequently worked as a cashier, in a hospital kitchen, and at a bowling alley. These jobs involved a lot of standing, but she did not experience any problems related to her pelvis or hips. At the time of the November 2016 examination, she experienced constant bilateral hip pain over the greater trochanters and neither hip seemed worse than the other. Her legs felt weak while climbing stairs, but this was likely due to her non service-connected peripheral neuropathy which was unrelated to the service-connected pelvic fractures. She experienced pain over the greater trochanters while lying on her sides at night, her hips would hurt if she stood for more than an hour (e.g. while cooking), and she experienced generalized body pain due to non service-connected fibromyalgia. She was able to walk a mile and sit without any hip problems. Furthermore, the Veteran did not describe any specific flare ups, symptoms of pain, or other difficulties due to her pubic rami fractures. The pain associated with her trochanteric bursitis would flare up with prolonged standing and she used medication to treat these flare ups. The bilateral trochanteric bursitis was not related to the service-connected pubic rami fractures. She would "take it easy" during flare ups of her fibromyalgia, but she otherwise did not report any functional loss due to any bursitis flare ups. She was unable to run due to her bursitis and experienced some functional limitations due to non service-connected fibromyalgia and back disability, but she did not otherwise report any functional loss or functional impairment of the right hip. The results of range of motion testing of each hip was recorded as flexion to 125 degrees, extension to 30 degrees, abduction to 45 degrees, adduction to 25 degrees, external rotation to 60 degrees, and internal rotation to 40 degrees. There was no pain associated with motion, no evidence of pain with weight-bearing, and no objective evidence of crepitus. There was tenderness over the bilateral greater trochanters, but this was not due to the service-connected pubic rami fractures. The Veteran was able to perform repetitive use testing with at least 3 repetitions and there was no additional loss of function or range of motion after 3 repetitions. The examiner noted that she was not being examined immediately after repetitive use over time or during a flare up, but the examination was medically consistent with her statements describing functional loss with repetitive use over time and during flare ups, and her functional ability was not significantly limited by pain, weakness, fatigability, or incoordination over a period of time or during flare ups. There were no other additional factors contributing to the Veteran's disability. Muscle strength associated with hip flexion, extension, and abduction was normal (5/5) and there was no muscle atrophy, hip ankylosis, malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The Veteran's gait was steady, but somewhat slow and broad-based due to peripheral neuropathy. She used a cane in her right hand, but did not put a lot of weight on it. The cane was not used on account of the service-connected pubic rami fractures since the Veteran's history, examination, and the records showed that the fractures had healed without residuals and she had other unrelated problems (peripheral neuropathy, foot pain, etc.) that affected her gait. There was no tenderness over the inguinal regions. Although there was tenderness bilaterally over the greater trochanters, this was symmetrical and was due to non service-connected trochanteric bursitis and fibromyalgia and not the service-connected pubic rami fractures. The Veteran's hip showed symmetrical motion, she was able to sit in and get out of a chair readily, she was able to cross her legs, there was no weakness or pain on weight-bearing, and she was able to internally and externally rotate normally. Her balance problems caused by peripheral neuropathy made her a little cautious while performing certain maneuvers, but she was able to perform them. For instance, she was able to get into a full squat, put more weight on her right leg than on the left while doing the squat, and did not walk with a limp. Moreover, there was no objective evidence of pain on active or passive motion of the hips, and there was no objective evidence of pain when either hip joint was used in weight-bearing or non weight-bearing. There were no scars associated with the Veteran's hip disability and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. X-rays of the right hip revealed slight contour irregularities of the right superior and inferior pubic rami which was reflective of old healed fractures. Also, there were minimal degenerative changes consistent with age-related changes. These degenerative changes were not significant enough or of sufficient severity to diagnose degenerative joint disease. Also, these findings were not due to the service-connected pubic rami fracture since they are in a different location and are consistent with age-related changes. Diagnoses of bilateral trochanteric pain syndrome and minimally displaced right superior and inferior pubic rami fractures were provided. The Veteran's disability did not impact her ability to perform any type of occupational tasks. The physician who conducted the November 2016 examination explained that the Veteran's history, the examination, the Veteran's medical records, and imaging results did not show that there were any residuals of the Veteran's right superior and inferior pubic rami fractures beyond the slight, and expected, cortical irregularities noted on x-ray. There were no current symptoms or positive examination findings related to the service-connected fractures. Although the Veteran reported hip pain, this was symmetric bilateral pain over the greater trochanters consistent with trochanteric bursitis. Examination revealed tenderness over the trochanters and this was consistent with the diagnosis of trochanteric bursitis. Any symptoms and positive examination findings reported in the November 2016 examination report were due to the bursitis and the Veteran's fibromyalgia, and they were not due to the service-connected fractures. Also, the bursitis and fibromyalgia were not residuals of the service-connected fractures. The examiner further explained that the current symptoms and examination findings did not involve the pubic rami because they were located in a different anatomical area (greater trochanters). The symptoms and examination findings were symmetrical, involving the right and left sides equally. Bilateral findings are not consistent with residuals of fractures on the right side. X-rays revealed that the fractures had healed well. This fact, in addition to the examination findings, served to indicate that there were no mechanical issues related to the pelvic fractures such that there would be any untoward stresses on the hips. The Veteran fell down a few steps in March 2014 and sustained a right hip contusion. This was the cause of the 2014 complaints of hip pain and the contusion had resolved. The greater trochanters are well known to be diagnostic tender points that are very commonly seen in fibromyalgia. The bursitis and fibromyalgia arose many years after the 1962 fractures were sustained. Minimally displaced stable pelvic fractures, such as those sustained by the Veteran, typically heal well. Trochanteric bursitis/trochanteric pain syndrome and fibromyalgia are not recognized residuals of healed remote pubic rami fractures. Moreover, based on the Veteran's history and examination, there was no objective evidence of pain on motion, weakness, excess fatigability, or incoordination associated with the pubic rami fractures. There was no pain on active or passive motion of the right hip, no functional loss of the right hip due to pain, flare ups, or repeated use, no ankylosis, and no flail joint. Also, based on examination findings, the Veteran's documented medical history and assertions, and treatment records, there was no evidence that her fractures of the right superior and inferior pubic rami with minimal deformity increased in severity since January 5, 1963. The examiner reasoned that history indicated that there were no problems due to the pelvic fractures in the years following the Veteran's discharge from service. She had no fracture related symptoms or difficulties during her 1964 pregnancy and vaginal delivery, she was able to work in jobs involving a lot of time on her feet, and she was able to do household chores and yard work. She was able to perform all of these activities without any symptoms or limitations due to the fractures. Her medical records following service did not show treatment for, or discuss symptoms due to, the pelvic fractures. Her current history and examination did not show any residuals of the pelvic fractures. X-rays showed that the fractures were well healed with only "slight contour irregularities." This is an expected finding and does not cause symptoms or limitations. The Veteran's current symptoms are due to bursitis and fibromyalgia and these disabilities arose many years later and were not due to the service-connected fractures. The symptoms that she experienced in 2014 were due to a hip contusion sustained in a fall, and they were not due to any exacerbation of the service-connected fractures. Minimally displaced and stable pelvic fractures, such as those sustained by the Veteran, typically heal well. Initially, the Board notes that, during the period under consideration, the Veteran has been diagnosed as having non service-connected fibromyalgia and trochanteric bursitis/pain syndrome. Where it is not medically possible to distinguish the symptoms of a service-connected disability from non-service connected manifestations, the benefit-of-the-doubt doctrine mandates that all manifestations will be considered in evaluating the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996)). Although the November 2016 examiner explained that the right hip symptoms described and observed during the November 2016 examination were due to non service-connected trochanteric bursitis/pain syndrome and fibromyalgia, there is no indication that the right hip/pelvic symptoms evident during the majority of the claim period prior to that examination can clearly be attributed to non service-connected disabilities as opposed to the service-connected pelvic fractures. Thus, the Board will afford the Veteran the benefit-of-the-doubt and attribute all of her right hip/pelvis symptoms to fractures of the right superior and inferior pubic rami with minimal deformity for the purposes of assessing the severity of that disability. Id. The above evidence reflects that there is limited information as to the manifestations of the service-connected fractures of the right superior and inferior pubic rami with minimal deformity during the period pertinent to this claim prior to November 6, 2007. During this period, the Veteran experienced right hip pain, pubic bone/pelvic pain, and limited right hip motion. The October 1962 service treatment record documents right hip pain, the April 1995 VA examination report reflects that there was limitation of right hip motion and x-ray findings of mild arthritic changes of the hip, and the December 1996 statement from the examiner who conducted the April 1995 VA examination indicates that the Veteran reported that she had experienced aches and pains in numerous joints (including the hips) since her in-service motor vehicle accident. The Board notes that there is no objective evidence of limited right hip motion or painful hip motion during the time period from the effective date of service connection (January 5, 1963) to the date of the April 1995 VA examination. As explained above, however, 38 C.F.R. § 4.59 does not require objective evidence of painful joint motion to warrant a minimum, compensable rating for a painful joint. Rather, credible evidence of actual joint pain is sufficient, even in the absence of painful motion. See Petitti, 27 Vet. App. at 415. In the present case, there is evidence of actual right hip pain during the claim period prior to November 6, 2007 (to include the entire period prior to the April 1995 VA examination). There is objective evidence of right hip pain in the Veteran's service treatment records and the Veteran reported during the April 1995 VA examination that the hip pain had continued in the years since service. The Veteran is competent to report that she experienced right hip pain in the years since service and there is no evidence to explicitly contradict her reports. Hence, the Board finds that the Veteran's reports of right hip pain in the years prior to the April 1995 VA examination are deemed credible. Moreover, there was objective evidence of limited right hip motion and hip arthritis at the time of the April 1995 examination. Accordingly, in light of the evidence of actual right hip pain, limited right hip motion, and hip arthritis, and the Court's holding in Petitti, and with resolution of all reasonable doubt in the Veteran's favor, the Board finds that the minimum, compensable rating under the limitation of motion codes pertaining to the hip joint (i.e., 10 percent) is warranted for fractures of the right superior and inferior pubic rami with minimal deformity for the entire period prior to November 6, 2007. See Petitti, 27 Vet. App. at 424-30; Burton, 25 Vet. App. at 3-5. However, a rating in excess of 10 percent for disability is not warranted at any time prior to November 6, 2007 or thereafter. Since the effective date of service connection, the Veteran's disability has been manifested by pain, tenderness, discomfort, stiffness, weakness, instability, and heat. The ranges of right hip motion have been limited to at most 82 degrees of flexion, 15 degrees of extension, 22 degrees of abduction, 25 degrees of adduction, 60 degrees of external rotation, and 40 degrees of internal rotation. These ranges of motion, by themselves and without consideration of potential functional impairment, are contemplated by no more than a 10 percent rating under the diagnostic codes pertaining to limitation of hip motion (DCs 5251-5253). As for functional impairment, the February 2008 and October 2009 VA examination reports do not document any hip pain on motion and the November 2016 VA examination report specifically indicates that there was no pain with active or passive motion on both weight-bearing and non weight-bearing of the hip. There was no pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use during the February 2008 and November 2016 examinations and the Veteran indicated during the November 2016 examination that there was no functional loss or functional impairment of the hip. Also, the Veteran has not reported any specific flare ups of her service-connected disability. Although she did report flare ups of her non service-connected trochanteric bursitis/pain syndrome during the November 2016 examination, the examiner specified that there was no functional loss due to such flare ups. Thus, even considering functional loss due to pain and other factors, the Veteran's symptoms have not been shown to be so disabling as to actually or effectively result in limitation of hip flexion to 30 degrees or limitation of abduction with motion lost beyond 10 degrees-the requirements for the next higher percent rating greater than 10 percent (i.e., 20 percent) for limitation of hip motion under DCs 5252 and 5253. The physician who conducted the November 2016 VA examination confirmed, based upon a review of the Veteran's medical records and reported history, that her disability did not increase in severity at any point since the effective date of service connection. Also, there has been no showing of any hip ankylosis, flail joint, or impairment of the femur at any time during the claim period and the absence of such impairments was specifically noted during the November 2016 examination. Hence, a rating in excess of 10 percent is not warranted on the basis of these impairments at any time since the effective date of service connection. 38 C.F.R. § 4.71a, DCs 5250, 5254, 5255. The Board further notes that the service-connected fractures of the right superior and inferior pubic rami with minimal deformity have not been shown to involve any other factor(s) warranting evaluation under any other provision(s) of VA's rating schedule at any pertinent point during the period under consideration.. Lastly, the Board finds that, in conjunction with the higher rating claim under consideration, neither the Veteran nor her representative has raised any other related issues, nor have any other such issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). (CONTINUED ON NEXT PAGE ORDER Service connection for peripheral neuropathy of the right lower extremity, to include as secondary to service-connected fractures of the right superior and inferior pubic rami with minimal deformity, is denied. Service connection for peripheral neuropathy of the left lower extremity, to include as secondary to service-connected fractures of the right superior and inferior pubic rami with minimal deformity, is denied. Service connection for a right elbow disability is denied. The claim for compensation under 38 U.S.C.A. § 1151 for degenerative joint disease with resection arthroplasty of the right wrist (claimed as a right hand and thumb disability) as a result of VA treatment is denied. An initial 10 percent rating for right superior and inferior pubic rami with minimal deformity, from January 5, 1963 to November 6, 2007, is granted, subject to the legal authority governing the payment of VA compensation. A rating higher than 10 percent for right superior and inferior pubic rami with minimal deformity is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs