Citation Nr: 1807122 Decision Date: 02/02/18 Archive Date: 02/14/18 DOCKET NO. 13-25 174 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a bilateral wrist disability. 2. Entitlement to service connection for a bilateral knee disability. 3. Entitlement to service connection for a low back disability. 4. Entitlement to service connection for a headache disability. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran and his mother ATTORNEY FOR THE BOARD J. Bayles, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from June 2001 to June 2005. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision by the Waco, Texas Department of Veterans Affairs (VA) Regional Office (RO). In October 2013, a hearing was held before a decision review officer (DRO) at the RO. In June 2015, a videoconference hearing was held before the undersigned. Transcripts of both hearings are in the record. In September 2015, the case was remanded for further development. The issue of service connection for a headache disability is being remanded to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if action on his part is required. FINDINGS OF FACT 1. The Veteran's wrist injuries in service were acute, did not involve bony pathology, and are shown to have resolved; a chronic disability of either wrist was not manifested in service; and any current chronic disability of either wrist is not shown to be etiologically related to the Veteran's service. 2. The Veteran's knees complaints in service were acute and resolved; a chronic right or left knee disability was not manifested in service or for many years thereafter; and any current knee disability is not shown to be etiologically related to the Veteran's service. 3. The Veteran's low back complaints in service were acute, and resolved; a chronic low back disability was not manifested in service or for many years thereafter, and any such disability is not shown to be etiologically related to the Veteran's service. CONCLUSIONS OF LAW 1. Service connection for a bilateral wrist disability is not warranted. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. Service connection for a bilateral knee disability is not warranted. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 3. Service connection for a low back disability is not warranted. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. VA's duty to notify was satisfied by correspondence in July 2010. See 38 U.S.C. §§ 5102, 5103, 5103A ; 38 C.F.R. § 3.159. At the June 2015 videoconference hearing, the undersigned identified the issues on appeal, explained the evidence needed to establish service connection for bilateral knee and wrist disabilities and a low back disability, and identified further evidence that could help substantiate the claims. His testimony reflects that he is aware of what was needed to substantiate the claims. The Veteran's service treatment records are associated with the record; they do not include a service separation examination report. In such circumstances VA has a heightened duty to explain its findings and conclusions and to consider carefully the benefit of the doubt rule. Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board's analysis of this claim is undertaken with this duty in mind. Notably, the cited caselaw does not lower the legal standard for proving a claim of service connection but rather increases the Board's obligation to evaluate and discuss in its decision all the evidence that may be favorable to the Veteran. Russo v. Brown, 9 Vet. App. 46 (1996). VA treatment records have been secured. The September 2015 remand ordered a search for treatment records from the 121st General Hospital in Yong Son Korea. An April 2017 letter notes that such records could not be located. An October 2017 letter was sent to the Veteran that asked him to complete and return the VA Form 21-4142, Authorization to Disclose Information, and VA Form 21-4142a, General Release for Medical Examiner Information, for each health care examiner that had treated his claimed condition, to specifically include Dr. McCray. He did not respond (and it is assumed that any private records that are outstanding do not support his claim). See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). He was afforded an examination in connection with these claims in September 2010. He declined the further examinations ordered in the September 2015 remand. The AOJ then sought medical advisory opinions based on review of the record (and given the Veteran's refusal to co-operate by presenting for VA examinations which may have elicited further pertinent information from the Veteran or provided additional factual data for consideration or submitting authorizations for private records), those medical opinions are the best medical evidence available. Legal Criteria, Factual Background, and Analysis The Board notes that it has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the Board discuss every piece of evidence in the record. Rather, the Board will summarize the relevant evidence, as deemed appropriate, and the analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Service connection may be granted for disability due to disease or injury incurred in or aggravated by military service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be evidence of: a current claimed disability; incurrence or aggravation of a disease or injury in service; and a nexus between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1153, 1166-67 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Certain chronic diseases, to include arthritis, may be presumed to be service connected if manifested to a compensable degree within a specified period of time following discharge from active duty (one year for arthritis). 38 U.S.C. § 1112,; 38 C.F.R. §§ 3.307, 3.309. Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When there is an approximate balance of positive and negative 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. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). An August 2001STR notes that the Veteran reported left knee pain when he ran. On examination there was no locking, trauma, swelling, twisting, or instability. The examiner found full range of motion and strength in each knee. The diagnosis was iliotibial band syndrome (ITBS) of the left knee. The Veteran was directed to stretch and take Motrin. A June 2002 STR notes that the Veteran reported right knee pain that had been present for 1 week. On examination, there was no edema, numbness, or loss of strength. Range of motion of the right knee was full . An August 2002 STR notes that the Veteran reported low back pain that had been present for two days and began when he picked up a box. He reported slight pain on walking; the examiner noted pain on flexion, but no swelling. An October 2002 STR notes that the Veteran reported a grinding sensation in his L5 and L4 vertebrae during exercise. It was noted that he was in a motor vehicle accident (MVA) in November 2000 (prior top service) when the car had rolled but had experienced only minimal injury. On examination, posture, gait, straight leg raise, and range of motion were normal. The examiner noted popping at L3-L4 during situps. No diagnosis was provided. An August 2004 STR notes that the Veteran reported right wrist pain that had been present for 5 days that occurred after a hyperextension injury. The diagnosis was right wrist sprain. The examiner also noted a left wrist sprain. A September 2004 STR notes that the Veteran reported that he reinjured his right wrist during a fall. He reported that his postal duties required heavy lifting. A splint was placed. A right wrist X-ray was unremarkable. The examiner recommended that the right wrist be casted to allow for soft tissue healing for four weeks, and a cast was placed; an October 2004 STR notes that the cast was removed from the right wrist. Range of motion of both wrist was noted to be within normal limits. The Veteran was advised that he could resume normal activity. A November 2004 STR notes that the Veteran was placed on a physical profile for wrist pain. A June 2010 knee X-ray found normal joint spaces and no evidence of fracture or other knee abnormality. A June 2010 private treatment record notes that the Veteran reported bilateral wrist pain that was constant and moderate in intensity. He reported that the wrist pain was aggravated by wrist flexion and extension and weight bearing but alleviated by rest. He reported that his wrist problem began after a fall in service. He reported that he was seen on multiple occasions in service for bilateral wrist pain. It was noted that he had reported continual pain since discharge from service, and had limited range of motion, difficulty lifting objects heavier than 10 pounds, and weight bearing on his wrists. A June 2010 private treatment record notes that the Veteran reported a history of knee pain that began in service after a MVA. He reported worsening symptoms of severe pain, dull ache, locking, popping, swelling, crepitation, and instability. It was noted that the Veteran continued to have debilitating, progressive pain with episodes of locking and instability since his discharge from service. He described related limitations. A June 2010 private treatment record notes that the Veteran reported a history of constant, severe, sharp, burning, low back pain that radiated to the left and right buttocks and anterior and posterior thighs. He reported that the low back pain began after a MVA in service . The examiner opined that the low back injury was secondary to a MVA in service and that since his discharge, the Veteran had had progressive continual pain with limited range of motion and difficulty walking. He noted that the Veteran would likely need pain management and/or surgical intervention in the near future to remain ambulatory. July 2010 bilateral X-rays of both wrists were interpreted as normal. On September 2010 VA wrist examination, the Veteran reported that he fell during service in September 2004 and had a cast placed on his left (STRs note right) wrist. He reported daily aching and pain in both wrists. The diagnosis was intermittent bilateral wrist strain. The wrists were normal on evaluation. The examiner opined that bilateral wrist disability was less likely as not caused by or a result of military service. He explained that the STRs did not establish chronicity for the claim. On September 2010 VA knee examination, the Veteran reported that his knees are painful equally on the lateral side of the distal thigh. He reported achiness, difficulty climbing stairs, and pain while jogging. He denied swelling and redness. He took Ibuprofen. The examiner noted that the knee examination was normal. The diagnosis was mild chondromalacia of both knees. The examiner opined that the bilateral knee disability was less likely than not caused by or a result of military service. He explained that the STRs did not support that a chronic disability was incurred in service. On September 2010 VA spine examination, the Veteran reported that his back was injured in a MVA in service. He reported that he went to the emergency room, received a diagnosis of lumbar strain, and was discharged. He reported that he has had low back pain since the MVA and that a prior episode of low back pain in 2002 was associated with recruit training and did not persist. He reported daily back pain of 5/10 severity. He reported that the pain increased with heavy lifting and was alleviated with rest. He took Ibuprofen as needed. He denied hospitalization, surgery, reinjury, and incontinence. The lumbar spine was normal on evaluation . The diagnosis was chronic, intermittent, lumbar strain. The examiner opined that the back disability was less likely as not caused by or a result of military service. He explained that the STRs did not establish that a chronic disability was incurred in service. A February 2012 VA treatment record notes that the Veteran reported chronic bilateral wrist and knee pain. He reported that he had occasional wrist swelling and knee pain that was localized to the lateral knees but had moved to the top of the knees after he began cycling. At the October 2013 DRO hearing, the Veteran reported that he had wrist problems since they appeared during basic training after doing push-ups. He reported a September 2004 temporary wrist profile, and that he wore a cast for four weeks. He reported that he had knee pain from running and hurt his back in a 2004 MVA during service. He reported that he took Advil as needed for pain. At the June 2015 videoconference hearing, the Veteran's representative reported that the Veteran was treated numerous times in service for wrist strain and that his occupation (administrative specialist and postal clerk) involved typing, repetitive motion, and moving mail bags which could cause wrist strain. The Veteran testified that he slipped, fell, and had his arm casted. X-rays did not show a fracture. He related that after service he continued to wrap his wrists, modify his movements, and use over-the-counter medication. As was noted above, the veteran refused examination, and the AOJ obtained VA medical advisory opinion regarding wrist disability based on review of the record. The examiner noted that STRs from August to October 2004 document a hyperextension injury from a fall on an outstretched hand that required casting . An October 2004 STR notes no pain or swelling and a full active range of motion. X-rays did not show joint or soft tissue swelling. The examiner opined that the Veteran's bilateral wrist disability was less likely than not caused or aggravated by an injury or event incurred in service. He explained that although he was unable to locate a separation evaluation in the records, it did appear that the wrist issues had resolved. He noted that there was no evidence of swelling in the wrist joint or the soft tissues in the 2004 wrist injury which would indicate acute trauma of the wrist. An October 2004 STR found normal right wrist active range of motion. The provider explained that repetitive trauma, as in mail handling or typing, is not an etiologic agent for an acute wrist sprain or any neurologic disorder as noted in the AMA Guides to Causation. Imaging studies of the wrists were essentially normal. The examiner notes that the first records of postservice treatment are from 2010, five years after the Veteran's discharge from service . The examiner expressed disagreement with Dr. McCray's 2010 findings, in which he notes bilateral wrist pathologies. The examiner notes that the objective clinical evaluation in 2010 is not consistent with the pathologies noted in the STRs, there is no documentation to establish proximity to time in service and discharge, and it is not consistent with any secondary pathologies that would evolve from those clinical findings noted in the STRs. The suggestion in the earlier wrist X-ray of a possible fracture is abrogated by the 2010 X-ray findings. He also noted that repetitive trauma is self-limiting and would not explain the chronicity and level of pain and 2010 objective findings noted in the McCray evaluation. He opined that the Veteran may have a connective tissue disorder or an injury to the triangular fibrocartilage complex (TFCC), but the etiology was not clear based on the information in the record. The AOJ also secured a November 2017 VA medical advisory opinion (based on review of the record) regarding the claimed bilateral knee disability. The examiner noted that the Veteran was involved in a MVA in November 2000 prior to entry into service. The service entrance examination was normal. An August 2001 STR notes the initial documentation for bilateral knee pain when the Veteran reported "popping and cracking only without swelling in the knees." The diagnosis was left knee ITBS and right knee chondromalacia. He removed himself from profile several weeks later. A June 2002 STR notes that diagnoses were bilateral shin splints and right knee "pain." No positive objective diagnostic or clinical findings were documented. The examiner opined that the Veteran's bilateral knee disability was less likely than not caused or aggravated by an injury or event incurred in service. He explained that although he was unable to locate a separation evaluation in the records, it appeared that the knee issues [in service] had resolved. The examiner noted that the first records of postservice treatment were from 2010, five years after the Veteran's discharge from service. There is no imaging evidence of knee pathology in service. The examiner explained that given the information currently available, the etiology of the bilateral knee pain is likely degenerative in nature given the objective findings and history documented by Dr. McCray and this degeneration, in the absence of any clinically significant trauma noted in the STRs is likely generic in nature. The provider expressed disagreement with Dr. McCray's 2010 findings. He explained that Dr. McCray's June 2010 evaluation was significant in that it documents objective clinical findings in the knees that are inconsistent with the STRs and the clinical states documented therein. His findings are consistent with torn menisci in the knees (with no imaging substantiation for such trauma described in the STRs). Furthermore, the only VA postservice records that the provider was able to identify revealed that in 2010 there were "no active problems" noted prior to June 2010, at which time the Veteran complained of bilateral knee crepitus. The examiner noted that there were no medical or employment records that he could identify to document bilateral knee pain or any work interference thereof consistent with the 2010 medical record of Dr. McCray that states the Veteran suffered "severe" bilateral knee from service to the time of the June 2010 McCray evaluation. The AOJ also obtained a November 2017 VA medical advisory opinion regarding low back disability. The provider noted that critical pieces of medical evidence not able to be identified include records from the 121st General Hospital in Yong Son, Korea documenting the claimed admission in 2004 or 2005 for the MVA that allegedly began the onset of the Veteran's low back pain. [Notably, an Ocotober 2002 STR identifies a November 2000, i.e., preservice, MVA as a precipitating factor for back pain.] An August 2002 STR notes that he reported low back pain after picking up a box. The evaluation was normal for pathology other than a strain. The October 2002 STR notes that the Veteran reported a "grinding sensation" in the area of the L4 and L5 vertebrae during stops and flutter kicks while exercising. He reported a pain level of 2/10 and was released to full activity. The provider opined that the Veteran's low back disability was less likely than not caused or aggravated by an injury or event in service. He explained that although he was unable to locate a separation evaluation in the records, it did appear that the low back issues in service had resolved. He noted that there was no X-ray evidence of any back pathology, and repetitive trauma was not an etiologic agent in recurrent lower back pain as noted in a seminal series of articles in the journal Spine. The provider noted that the first records of postservice low back treatment are from 2010, five years after the Veteran's service discharge, and examiner opined that in the absence of the above noted records, the current etiology of the Veteran's back pain is likely early degenerative in nature, and the other possibility is a connective tissue disorder or an inflammatory disorder such as a spondylolytic sponylolisthesis. There was nothing on the imaging studies to suggest a primary boney disorder. The provider expressed disagreement with Dr. McCray's 2010 findings noting ongoing back pain. He found the evaluation of Dr. McCray in June 2010 significant in that it documents objective clinical findings in the back inconsistent with the STRs and the clinical states documented therein. He noted that the findings are consistent with a high index of suspicion for radiculopathy that had no imaging substantiation for trauma as described in the STRs. He explained that there was no indication that Dr. McCray reviewed the medical history in the STRs and as such, he could not possibly relate the Veteran's pathology to service on an objective basis but only on the basis of the Veteran's reported history. Further, there were no medical or employment records identifiable that document low back pain or any work interference thereof consistent with the 2010 medical record of Dr. McCray that stated the Veteran suffered progressive central low back pain from the time the precipitating events for these symptoms allegedly occurred (in service) to the time of the McCray evaluation in June 2010. Wrists It is not in dispute that the Veteran has a bilateral wrist disability, as intermittent bilateral wrist strain was diagnosed on September 2010 VA examination. It is also not in dispute that he injured his wrists in service in August 2004 when he fell. His STRs show that his wrists were treated and the diagnosis was bilateral wrist strain. These injuries apparently resolved with treatment. While the record does not include a service separation report, the STRs do not show continuing treatment after November 2004. The initial postservice report of wrist pain in the record was in June 2010 (when the Veteran was seen by a private provider), 5 years after discharge from service. Notably, postservice VA treatment records show that the Veteran did not receive an assessment of bilateral wrist strain until September 2010. Consequently, service connection for a bilateral wrist disability on the basis that such disability became manifest in service and persisted is not warranted. What remains for consideration is (in the absence of a showing of onset in service and continuity of complaints/symptoms since), the Veteran's current bilateral wrist disability may be related to his remote service/complaints and injury therein. Whether there is a nexus between a current wrist disability and service or complaints therein, absent evidence of continuity, is a medical question that requires medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board found both the June 2010 and the VA September 2010 opinions in the matter inadequate and remanded the matter for development to include for private treatment records and for another, more complete examination and medical opinion. As was noted above, the Veteran did not respond to a request for authorization for VA to secure private treatment records, and refused further examination. Consequently, the AOJ sought a medical advisory opinion in the matter (which the Board finds adequate, and the best available medical evidence on the medical question presented). The November 2017 VA consulting provider opined that the Veteran's bilateral wrist disability was less likely than not incurred in or caused by the injury in service. He explained that (based on medical literature) repetitive trauma, as in mail handling or typing, is not an etiologic agent for an acute wrist sprain or any neurologic disorder. He noted that the record did not in fact shown continuity of complaints. As the VA examiner's opinion reflects familiarity with the record, and includes a rationale with citation to supporting factual data, the Board finds it to be highly probative evidence in the matter. In the absence of competent evidence to the contrary, the Board finds it persuasive. The Veteran's reports of continuity of symptoms are self-serving, and are not supported by contemporaneous data. Therefore, they are not credible. His assertions that his bilateral wrist disability is related to injury/his complaints in service are not competent evidence. He is a layperson and is not competent to offer an opinion regarding a nexus between a disability first documented five years after service and complaints noted in service in the absence of continuity or probative supportive medical evidence. See Jandreau, 492 F. 3d at 1377. In light of the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for a bilateral wrist disability. Therefore, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The appeal in the matter must be denied. Bilateral knees It is not in dispute that the Veteran has a bilateral knee disability, as mild chondromalacia of both knees was diagnosed on September 2010 VA examination. It is also not in dispute that during service he reported knee pain (in August 2001 and June 2002). However, the complaints/injuries in STRs show resolved with treatment, and a chronic knee disability in service is not shown. The initial postservice report of knee pain in the record was in June 2010 (5 years after discharge from service) when the Veteran reported knee pain in the course of private treatment; chondromalacia of both knees was diagnosed by VA several months later. Consequently, service connection for a bilateral knee disability on the basis that such disability became manifest in service and persisted is not warranted. As arthritis of the knees has not been diagnosed, the chronic disease presumptive provisions under 38 U.S.C. § 1112 do not apply. What remains for consideration is whether (in the absence of a showing of onset in service and continuity of complaints/symptoms since), the Veteran's current bilateral knee disability may be related to his remote service/complaints and injury therein. Whether there is a nexus between a current knee disability and service or complaints therein, absent evidence of continuity, is a medical question that requires medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A September 2010 VA examiner's opinion in the matter is inadequate for rating purposes because it did not account for a June 2010 private provider's assessment that the Veteran was treated for his knees in service and has continued to have problems since. A December 2010 private physician's opinion suggests that the Veteran had continual debilitating, progressive pain with episodes of locking and instability since his discharge from service. The Board sought development for the provider's records (to discern whether they support continuity). The Veteran did not reply to the request, and the inference is that any existing private treatment records do not support continuity. The opinion is therefore based solely on the Veteran's reported history, which as noted above the Board has found not credible. Therefore, it is without probative value in this matter. The only probative medical evidence of record in the matter is against this claim. The November 2017 VA examiner opined that the Veteran's bilateral knee disability was less likely than not incurred in or caused by the claimed in-service injury. The examiner explained that there was no X-ray evidence in service of knee pathology, and that the etiology of [the Veteran's current] bilateral knee pain was likely degenerative and generic in nature; the first record of postservice treatment was in 2010, five years after the Veteran's service discharge. He also noted that the June 2010 private opinion documents objective clinical findings for the knees that are inconsistent with the STRs and the clinical states documented therein. As the VA examiner's opinion reflects familiarity with the record, and includes a rationale with citation to supporting factual data, the Board finds it to be highly probative evidence in the matter. In the absence of competent evidence to the contrary, the Board finds it persuasive. AS the Veteran is a layperson, his own opinion regarding the etiology of his bilateral knee disability is, in the absence of evidence of continuity, not competent evidence in the matter. See Jandreau, 492 F. 3d at 1377. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim of service connection for a bilateral knee disability. Therefore, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The appeal in this matter must be denied. Low back It is not in dispute that the Veteran has a low back disability, as chronic, intermittent, lumbar strain was diagnosed on September 2010 VA examination. It is also not in dispute that during service he seen for back pain following a lifting injury in August 2002 and was seen again in October 2002 (when a pre-service MVA was noted); a low back disability was not then diagnosed. The injuries in service apparently resolved with treatment (as there is no record of follow-up). The initial postservice report of low back pain in the record was in June 2010 (5 years after discharge from service) when the Veteran reported back pain during private treatment. Chronic, intermittent, lumbar strain was first diagnosed in September 2010. Consequently, service connection for a low back disability on the basis that such disability became manifest in service and persisted is not warranted. As arthritis of the low back has not been diagnosed, the chronic disease presumptive provisions under 38 U.S.C. §§ 1112, 1137 have no application. What remains for consideration is (in the absence of a showing of onset in service and continuity of complaints/symptoms since), the Veteran's current low back disability may be related to his remote service/complaints and injury therein. That is a medical question that requires medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A September 2010 VA examiner's opinion (against the claim) was deemed inadequate for rating purposes because it did not account for a private provider's earlier report indicating that the Veteran has had continuity of back problems since service The December 2010 private physician's opinion suggests that the Veteran's low back injury was secondary to a MVA in service [as was noted previously, the MVA clinically noted in STRs occurred prior to service]; the Veteran's more recent accounts of a later injury in service are not corroborated, and are deemed self-serving and not credible (including because they are inconsistent with contemporaneous clinical data). Notably, the Board sought to assist the Veteran in corroborating his allegations and by arranging for a VA examination; but the Veteran did not respond to a request for authorization for VA to secure private treatment records and refused a VA examination. Consequently, the best available medical evidence regarding the etiology of the Veteran's back disability is in the November 2017 VA medical advisory opinion based on review of the record. The examiner provided a clear explanation of rationale, noting that there was no X-ray evidence in service of any back pathology, that repetitive trauma was not an etiologic agent for the current disability, and that there was no continuity of complaints (as the first records of postservice treatment for the back were from 2010, five years after the Veteran's service discharge). He noted that the current etiology of the Veteran's back pain is likely early degenerative in nature, or an inflammatory disorder such as a spondylolytic spondylolisthesis. He also addressed the private opinion that attributed the Veteran's disability to injury in service, noting that the injury was not documented in records, and that opinion must have been based solely on the Veteran's reports. As the VA examiner's opinion reflects familiarity with the record, and includes a rationale with citation to supporting factual data, the Board finds it to be highly probative evidence in the matter. In the absence of competent evidence to the contrary, the Board finds it persuasive. The Veteran's own assertions that his low back disability is due to an incident in service are not competent evidence in the matter. In the absence of a showing of chronic disability in service (here, not found on X-ray) or continuity of complaints thereafter (the Veteran's accounts of which the Board found not credible), whether there is a nexus between a current back disability such as the strain shown here and a lifting injury or complaints in remote service is a medical question. The Veteran is a layperson, and does not cite to supporting medical opinion or literature. In light of the foregoing, the Board finds that the preponderance of the evidence is against this claim. Therefore, the benefit of the doubt rule does not apply. The appeal in the matter must be denied. ORDER Service connection for a bilateral wrist disability is denied. Service connection for a bilateral knee disability is denied. Service connection for a low back disability is denied. REMAND Further development of the record is again needed for a proper adjudication of the claim seeking service connection for a headache disability. The Veteran refused to appear for a VA examination requested by the AOJ . As this is an original claim for compensation , the claim would be decided based on the evidence of record. See 38 C.F.R. § 3.655(b). However, the record presents a medical question that is not adequately addressed by competent evidence therein (there are conflicting opinions regarding the nature and etiology of the claimed headache disability that cannot be reconciled without further medical opinion guidance). An advisory medical opinion based on review of the record is necessary opinions. Accordingly, the case is REMANDED for the following : 1. The AOJ should arrange for a neurologist to review the record and opine whether the Veteran has a headache disability that is related to his service. The Veteran's entire VA record must be reviewed by the consulting physician. Upon review of the record, the consulting examiner should provide an opinion that responds to the following: Please identify the likely etiology for the Veteran's current headache disability. Specifically, is it at least as likely as not (a 50% or greater probability) that it is related to his service, to include as related to complaints/treatment therein? The consulting examiner must explain the rationale for the opinion (specifically addressing the June 2010 private provider's report suggesting continuity of headache problems since service), and accounting for a buddy statement by a fellow service-person in the record indicating that the Veteran had severe headaches in service (and that they have persisted). The examiner should also expressly indicate whether there is anything regarding the Veteran's headache disability that suggests when it was incurred or the etiological factor implicated. 2. The AOJ should then review the record and readjudicate the claim. If the claim remains denied, the AOJ should issue an appropriate supplemental statement of the case and afford the Veteran and his representative opportunity to respond before returning the case to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs