Citation Nr: 21001122 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 16-41 549 DATE: January 7, 2021 ORDER Entitlement to an initial compensable rating for right fifth metacarpophalangeal (MCP) open dislocation with scar (right fifth finger disability with scar) is denied. Entitlement to service connection for a low back disability is denied. FINDINGS OF FACT 1. The Veteran’s right fifth finger disability is not manifested by symptoms approximating an amputation of that finger, or by involvement of other fingers or the whole hand so as to warrant a compensable or separate rating. 2. The Veteran’s right fifth finger scar has not been found to be unstable or painful; the scar does not cover an area of 144 square inches and causes no functional limitation. 3. The Veteran’s low back disability did not originate in service, within a year of service, and is not otherwise etiologically related to the Veteran’s active service. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for a right fifth finger disability with scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, 4.118, Diagnostic Codes (DCs) 5227, 5230, 7805. 2. The criteria for service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1996 to January 2000. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In June 2019, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. By way of background, these matters were previously before the Board in November 2019, when they were remanded for additional development. Lastly, the Board notes that the Veteran filed a timely appeal to a July 2019 statement of the case (SOC) for the issue of entitlement to service connection for insomnia. See September 2019 VA Form 10182 Notice of Disagreement. However, in the September 2019 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected a Hearing with a Veterans Law Judge. 38 C.F.R. § 19.2(d). Thus, the issue of entitlement to service connection for insomnia will be addressed in a separate decision. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an initial compensable rating for a right fifth finger disability with scar is denied. As an initial matter, the Veteran filed his claim for entitlement to service connection for damage to his hand on January 7, 2013. See January 2013 VA Form 21-526 Veterans Application for Compensation or Pension. The RO granted service connection for a right fifth MCP open dislocation with scar in a January 2014 rating decision and assigned a noncompensable rating, effective January 7, 2013. See January 2014 Rating Decision – Narrative. Throughout the period on appeal, the Veteran’s right fifth finger disability with scar has been evaluated under DC 5230. 38 C.F.R. § 4.71a. Under Diagnostic Code 5230, a noncompensable (zero percent) disability rating is assigned for any limitation of motion of the ring or little finger. 38 C.F.R. § 4.71a. A noncompensable evaluation is the only evaluation available under this Diagnostic Code. The Board notes that for digits II through V, the MCP joint has a range of zero to 90 degrees of flexion, the proximal interphalangeal joint has a range of zero to 100 degrees of flexion, and the distal (terminal) interphalangeal joint has a range of zero to 70 or 80 degrees of flexion. 38 C.F.R. § 4.71a (Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, Note (1)). Turning to the evidence of record, a January 2014 private treatment record shows that the Veteran had an open fracture of his fifth proximal phalanx from a fall with an overlapping scar. The private physician noted that the Veteran had decreased ROM at his first MCP and proximal interphalangeal (PIP) joints with pain. The Veteran endorsed increased pain when he gripped someone’s hand and with repetitive movement, and the examiner found decreased ROM at the right fifth MCP and PIP joints, which resulted in mild disability when the Veteran used his right hand. See January 2014 Medical Treatment Records – Non-Government Facility. The Veteran initially underwent a VA examination for hand and finger conditions in January 2014. The examiner noted that the Veteran had been diagnosed with a right fifth MCP open dislocation and that he was right hand dominant. During the examination, the Veteran denied flare-ups. Range of motion (ROM) testing revealed limitation of motion in the Veteran’s right little finger, but the examiner found no objective evidence of painful motion. In addition, the Veteran was able to perform repetitive use testing without additional limitation of motion. The examiner found evidence of weakened movement, excess fatigability, and swelling in the Veteran’s right little finger but did not find evidence of ankylosis. The examiner further noted that the Veteran had a scar related to his right fifth finger disability, but found that it was not painful or unstable and that it did not cover a total area of 39 square centimeters. See January 2014 C&P examination. In support of his claim, the Veteran submitted a private Disability Benefits Questionnaire (DBQ), from Dr. Terry L. Winegar, dated in January 2014. Dr. Winegar noted that the Veteran had been diagnosed with a proximal phalanx fracture and that he was right hand dominant. During the examination, the Veteran endorsed flareups, which were manifested by pain and decreased right fifth finger range of motion. On examination, Dr. Winegar found limitation of motion or painful motion in the Veteran’s right little finger and noted contributing factors of disability, to include less movement than normal, weakened movement, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, swelling, and deformity. Muscle strength testing revealed active movement eliminated with gravity, but there was no evidence of ankylosis. Following the examination, Dr. Winegar reported that the Veteran’s right fifth finger disability limited his ability to shake hands and grip and decreased ROM and use of the right fifth digit of his hand. See January 2014 VA examination. In support of his claim, the Veteran also submitted a private medical opinion from Dr. Winegar, dated in June 2019. After performing an evaluation, Dr. Winegar reported that the Veteran’s fifth finger laceration caused decreased function and ROM. See July 2019 Medical Treatment Record – Non-Government Facility. During the June 2019 Board hearing, the Veteran testified that, as a result of his right fifth MCP open dislocation, he has painful scar tissue and nerve pain that prevents him from being able to fully close his hand. See June 2019 Hearing Transcript, pages 2, 3, 5. The Veteran was afforded a VA examination for hand and finger conditions in February 2020. The examiner noted that the Veteran had been diagnosed with right fifth MCP open dislocation with scar and that he was right hand dominant. During the examination, the Veteran reported that he could not bend his finger and that he “bab[ied]” it due to pain. The examiner reported that he was unable to perform range of motion (ROM) testing because the Veteran refused to clench his entire fist, and when asked if he could move his right finger joint, the Veteran refused to flex or move it because he wanted to avoid pain. However, the examiner found that the Veteran was able to move all of the other fingers on his right hand; the examiner further reported that the Veteran was able to flex his fifth finger joint when asked to perform additional maneuvers but later backtracked and refused to move the finger. The examiner further noted that there was no single complaint regarding the Veteran’s right finger disability in his medical records over the preceding five years, despite his reports that he regularly sought treatment, and a November 2013 x-ray of the Veteran’s right hand was negative. Thus, the examiner found that the Veteran was not cooperating with the examination or willing to participate, and as a result, the examiner was unable to provide an accurate depiction of the Veteran’s true ROM capacity. Muscle strength testing was normal, and the examiner found no evidence of pain or ankylosis on examination. The examiner reported that the Veteran denied flare-ups, functional loss, and functional impairment. The examiner did note that the Veteran reported that his right fifth finger joint became recurrently swollen and that he stated that the joint was swollen on the date of the examination. However, the examiner did not find any evidence of effusion on examination, and passive movement did not elicit any visible signs of pain. See February 2020 CAPRI. Lastly, the Veteran was also afforded a VA examination for scars and disfigurement in February 2020. The examiner reported that the Veteran had a scar on his right fifth finger from an injury in August 1998. Specifically, the examiner reported that the Veteran had one scar on his right fifth finger, which measured 1.5 centimeters by 0.2 centimeters. The scar was not found to be painful, unstable, or caused by burns, and the examiner did not find evidence of any muscle or nerve damage associated with the scar. The examiner also found that the Veteran’s scar did not impact his ability to work. Following the examination, the examiner opined that the Veteran’s right fifth finger scar was at least as likely as not due to the claimed in-service injury. In support of his opinion, the examiner stated that the scar noted during the examination corresponded to the area that the Veteran injured in service. See February 2020 C&P examination. Following a review of the evidence of record, the Board finds that an initial compensable rating for a right fifth finger disability is not warranted. As an initial matter, the Board notes that the February 2020 examiner found that the Veteran was not cooperating with the examination or willing to participate, and as a result, the examiner was unable to provide an accurate depiction of the Veteran’s true ROM capacity. Specifically, the Veteran refused to move his right little finger during the examination due to pain but was able to flex his fifth finger joint when asked to perform additional maneuvers. In addition, the examiner noted that there was no single complaint regarding the Veteran’s right finger disability in his medical records over the preceding five years, and a November 2013 x-ray of the Veteran’s right hand was negative. The duty to assist in developing the facts and evidence pertinent to a veteran’s claim is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Rather, it is a veteran’s responsibility to cooperate with VA, including with any efforts to provide an adequate medical examination. See Caffrey v. Brown, 6 Vet. App. 377, 383 (1994); Olson v. Principi, 3 Vet. App. 480, 483 (1992). In light of the fact that the Veteran was found unwilling to participate with the February 2020 VA examination and as that examination was obtained in order to further develop his claim, the Board finds that remanding this matter for the sole purpose of obtaining another VA examination would service no useful purpose. The Board further finds that VA has satisfied the duty to assist provisions of law with regard to the claim on appeal, and, therefore, finds there was substantial compliance with the requested development. Dyment v. West, 13 Vet. App. 141 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Since the Veteran is already receiving the maximum scheduler evaluation permitted under DC 5230, the Board will consider other potentially applicable Diagnostic Codes in the Rating Schedule. Under DC 5227, a maximum noncompensable rating is assigned for unfavorable or favorable ankylosis of the ring or little finger regardless of whether the finger is on the major (dominant) or minor (non-dominant) hand. 38 C.F.R. § 4.71A, DC 5227. Although the Board recognizes that the Veteran currently is in receipt of the maximum zero percent disability rating, the Note to Diagnostic Code 5227 states that an amputation evaluation should also be considered, particularly where ankylosis is present. 38 C.F.R. § 4.71a. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992). Here, there is no competent evidence suggesting that the Veteran experiences ankylosis in his right fifth finger. 38 C.F.R. § 4.71a, DC 5227. Specifically, ankylosis of the finger was not documented in the January 2014 or February 2020 VA examination reports, and no ankylosis was noted in the January 2014 private DBQ from Dr. Winegar. See January 2014 C&P examination; January 2014 VA examination; February 2020 CAPRI. In addition, neither VA nor the private treatment records reflect any indication of ankylosis. Moreover, no evidence of record indicates that the right fifth finger is so disabled by any other symptoms, to include pain, such that its functional impairment more nearly approximates amputation. Thus, the Board concludes that an increased rating is not warranted via the amputation codes because the nature of the Veteran’s service-connected right fifth finger disability, coupled with the absence of ankylosis is not analogous to amputation. 38 C.F.R. § 4.71a, DC 5156. The Board further recognizes the Veteran's lay statements of pain and swelling in his right fifth finger. In this regard, while it is the intention of the rating schedule to recognize actually painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, there is no compensable rating available under either DC 5230 or DC 5227. 38 C.F.R. § 4.71a. Additionally, the provisions of 38 C.F.R. §§ 4.40, 4.45 are not for consideration where the Veteran is in receipt of the highest rating based on limitation of motion and a higher rating requires ankylosis. Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). Because the Veteran is already receiving the maximum schedular rating based on symptomatology that includes limitation of motion under DC 5230, an increased rating under 38 C.F.R. §§ 4.40 and 4.45 is not available. The Board recognizes that the Veteran has a scar on his right fifth finger associated with his service-connected right fifth finger disability. In this regard, the Board notes that the Veteran was afforded a VA examination for scars and disfigurement in February 2020, which found that the Veteran had a scar measuring 1.5 centimeters by 0.2 centimeters on his right fifth finger. See February 2020 C&P examination. The Board further acknowledges the Veteran’s lay statements that, as a result of his right fifth finger disability, he has painful scar tissue and nerve pain that prevents him from being able to fully close his hand. See June 2019 Hearing Transcript, pages 2, 3, 5. In this regard, the Board notes that a Veteran is competent to report purported symptoms such as pain or whether he has received a diagnosis from a medical professional. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). However, to the extent that the Veteran’s statements may suggest that his right fifth finger scar is painful, the Board finds that the medical evidence of record weighs against a finding that the Veteran’s reports of pain can be attributable to his scar. Rather, the evidence of record reflects that any pain is related to the Veteran’s underlying right fifth finger disability. See February 2020 C&P examination. Thus, the Board finds that the Veteran’s scar has not been of the severity or size to warrant a compensable rating under the rating criteria pertaining to scars. See 38 C.F.R. § 4.118, DCs 7801-7805. Accordingly, a separate compensable rating for scarring is not warranted. In sum, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s right fifth finger disability more nearly approximates the criteria for a higher rating under DC 5230. The Board notes that there are no other applicable diagnostic codes that would afford the Veteran a compensable schedular rating in excess of 10 percent, to include DCs 5227 and 7801-7805. Therefore, a compensable rating is not warranted. 38 C.F.R. §§ 4.71a, DC 5230. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be presumed for certain chronic diseases which develop to a compensable degree within one year after discharge from service, even though there is no evidence of the disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1137; 38 C.F.R. §§ 3.307, 3.309(a). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for a low back disability is denied. During the June 2019 hearing, the Veteran testified that his back disability was caused by an injury he sustained while he was serving on active duty. Specifically, the Veteran reported that he slipped while sliding down a ladder and fell approximately 20 feet in or around April or May 1997. The Veteran further testified that he sustained a serious arm injury from the fall and experienced intermittent soreness in his back, thereafter. The Veteran stated that he was taken to Portsmouth Hospital for his arm injury and reported soreness and a headache at that time; however, the Veteran testified that he did not report the back injury to his in-service doctors because it occurred approximately two weeks after he received his first command and he was frightened as a new seaman. To this end, the Veteran reported that he experienced paralyzing back pain a few months after he was discharged from service and initially sought treatment at the VA clinic. See June 2019 Hearing Transcript, pages 8-14. A review of the Veteran’s service treatment records (STRs) shows a May 1996 enlistment report of medical examination that is absent for findings pertaining to the Veteran’s spine and other musculoskeletal system. In May 1997, the Veteran sustained an injury to his right elbow after he slipped while descending the stairs of a ladder. The Veteran reported that he fell while his arm was holding the rail, dislocating the elbow. Thereafter, the Veteran pulled his arm into extension partially reducing elbow swelling. The assessment was “probable?” posterior dislocation of the right elbow, self-reduced. The Veteran denied recurrent back pain on an October 1997 sea duty screening form. A February 1999 physical evaluation board report of medical examination shows the Veteran’s spine and other musculoskeletal system to be normal, and the Veteran continued to deny recurrent back pain on the corresponding report of medical history. See January 2000 STR – Medical – Photocopy; January 2000 STR – Medical. In July 2000, the Veteran reported that he had been experiencing joint pain for six months but did not specify which joints were affected. Thereafter, a January 2001 primary care physician note shows that the Veteran endorsed low back pain. The Veteran reported that the pain manifested after he wrestled with a friend four weeks prior but denied injury. In August 2002, the Veteran endorsed severe lumbar back pain that radiated into his right hip. He stated that he had been in good health until four days prior to admission when he began experiencing significant but not debilitating low back pain, which significantly worsened while he was picking up a blanket. The Veteran reported that he was unable to walk without falling. The assessment included acute low back pain without neurological deficits. The Veteran underwent a lumbar spine MRI in August 2002, which revealed a large central L5-1 herniated disc and minimal scattered osteogenic and discogenic degenerative changes. In March 2008, the Veteran reported that he injured his back while he was serving on active duty. However, the examiner reported that the Veteran somaticized a lot, and while the Veteran stated that previous x-rays of his back were abnormal, the examiner found no evidence of abnormal back x-rays in the Veteran’s chart. The assessment included low back pain. See November 2019 CAPRI. The Veteran initially underwent a VA examination for back conditions in January 2014. The examiner noted that the Veteran had been diagnosed with spondylosis. During the examination, the Veteran reported that he initially injured his back when he fell down a ladder in 1997, and reported that he had continued to experience chronic back pain since the in-service incident. He also endorsed flare-ups, during which he was unable to walk. The examiner found that the Veteran had functional loss and/or functional impairment of the thoracolumbar spine and noted contributing factors of disability, to include, less movement than normal, excess fatigability, pain on movement, disturbance of locomotion, interference with sitting, standing and/or weight-bearing, and lack of endurance. Imaging studies of the Veteran’s lumbar spine revealed evidence of arthritis, and the examiner noted that the Veteran’s spondylosis impacted his ability work because it limited his ability to bend and lift. After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran’s diagnosed back disability was incurred in or caused by the claimed in-service injury, event, or illness. In support of his opinion, the examiner noted that there was no indication or complains of back pain after the Veteran’s in-service fall. To this end, the examiner stated that the Veteran sought treatment for elbow and hand injuries following the accident, as was noted in multiple medical assessments, but there was no indication of chronic back pain. See February 2020 CAPRI. In support of his claim, the Veteran submitted a private DBQ, dated in January 2014, from Dr. Terry L. Winegar. Dr. Winegar diagnosed the Veteran with lumbar spine sprain and lumbar spine spondylosis without myelopathy or radiculopathy. Dr. Winegar noted that the Veteran had been experiencing back pain since his 1997 fall, which had worsened over time. During the examination, the Veteran endorsed flare-ups manifested by severe pain and spasms. Dr. Winegar further found that the Veteran had intervertebral disc syndrome, which was manifested by incapacitating episodes and noted that the Veteran experienced daily low back pain. See January 2014 VA examination. The Veteran also submitted a medical opinion from Dr. Winegar, dated in January 2014. Dr. Winegar opined that it was more likely than not that the Veteran’s current low back disability was directly related to his active duty service. In this regard, Dr. Winegar noted that the Veteran had been experiencing pain in his low back since service, and that he appeared to have osteoarthrosis of the lumbar spine due to a traumatic fall and injury he sustained during service. See January 2014 Medical Treatment Record – Non-Government Facility. VA obtained an addendum opinion in February 2016. The examiner opined that the January 2014 medical opinion documenting service connection of the Veteran’s injuries was unchanged by the new evidence. VA also obtained an addendum opinion in June 2016. Following a review of the evidence of record, the examiner opined that the Veteran’s current back disability was not service connected and found there was no evidence to the contrary. To this end, the examiner stated that the examinations and medical opinions proffered by private physicians 14 years after the Veteran’s in-service fall could not constitute evidence that the Veteran sustained a back injury during service. In this regard, the examiner noted that there were no notations of back pain in the Veteran’s STRs. See January 2020 CAPRI. In support of his claim, the Veteran also submitted a medical opinion from Dr. Winegar, dated in June 2019. Dr. Winegar stated that, based on a review of all of the evidence in the Veteran’s history, it was more likely than not that the Veteran’s low back pain originated while he was serving on active duty and was probably caused by his active military service. In this regard, Dr. Winegar noted that he reviewed his notes on the Veteran’s lower back pain and stated that the Veteran reported that he injured his back while he was serving on active duty and that he had been seeing doctors since 2001. Dr. Winegar further noted that he had been treating the Veteran since 2012 and reported that the Veteran had been diagnosed with an L5-S1 disc protrusion and mild bilateral neuroforaminal stenosis. As such, Dr. Winegar opined that the Veteran’s low back pain was related to his active military service. See July 2019 Medical Treatment Record – Non-Government Facility. After a review of the evidence of record, the Board finds that service connection for a low back disability is not warranted. In the present case, there is sufficient evidence the Veteran meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Specifically, the January 2014 VA examiner noted that the Veteran had been diagnosed with spondylosis, and Dr. Winegar reported that he had diagnosed the Veteran with an L5-S1 disc protrusion and mild bilateral neuroforaminal stenosis in the June 2019 private medical opinion. See January 2020 CAPRI; July 2019 Medical Treatment Record – Non-Government Facility. As such, the remaining question is whether his lumbar spine disability is related to service. With respect to an in-service injury or disease, the Board concludes that the most probative evidence does not show that the Veteran injured his low back during service. The Board finds the Veteran’s STRs, which do not reveal any complaints of, or treatment for, a low back injury during service, the most probative evidence of record, as they were created contemporaneous with his service, and addressed the in-service fall. To this end, the Board notes that when asked during service, the Veteran denied back pain, and his February 1999 physical evaluation board report of medical examination shows that he did not have any spine or other musculoskeletal disabilities. See January 2000 STR – Medical – Photocopy; January 2000 STR – Medical; November 2019 CAPRI. The Board further notes that the Veteran has provided conflicting statements regarding the onset of his symptoms. In this regard, during his June 2019 hearing, the Veteran testified that he began experiencing pain and soreness in his back after he slipped while sliding down a ladder and fell approximately 20 feet in or around April or May 1997. The Veteran stated that he was taken to Portsmouth Hospital for his arm injury and reported soreness and a headache at that time; however, the Veteran testified that he did not report the back injury to his in-service doctors because it occurred approximately two weeks after he received his first command and he was frightened of getting into trouble as a new seaman. In this regard, the Veteran reported that he did not seek treatment until approximately 2001 or 2002. See June 2019 Hearing Transcript, pages 8-10. However, a January 2001 primary care physician note shows that the Veteran reported that he had been experiencing low back pain for four weeks and stated that the pain manifested after he wrestled with a friend. Thereafter, in August 2002, the Veteran reported that he had been in good health until four days prior, when he began experiencing severe but not debilitating low back pain, which subsequently worsened. See November 2019 CAPRI. Moreover, although the Veteran testified that he did not report his back pain at the time he was treated following the fall from the ladder because he was afraid of getting into trouble, the Board does not find this report credible. It does not logically follow that the Veteran would report one injury (elbow) and receive treatment, but would not report another injury/pain (low back). It is not clear to the Board why the Veteran would not report back pain, especially since he received rehabilitation for his elbow, and he could have received treatment for any back pain at the same time. The Board emphasizes that the evidence of record shows that the Veteran initially reported that he sustained a back injury during service in March 2008, approximately eight years after the Veteran was discharged military service. See November 2019 CAPRI. Accordingly, as the Veteran has provided conflicting statements as to the onset of his lumbar spine disability, the Board finds the Veteran an inaccurate historian with regard to the issue on appeal. Thus, as the Veteran’s lay statements are unreliable the Board concludes that they are of little probative value. The Board also notes that there are conflicting medical opinions of record as to whether the Veteran’s current low back disability is related to service. After a review of those opinions, the Board finds the January 2014 VA examination report and June 2016 addendum medical opinion, when considered together, to be the most probative evidence of record. In this regard, the Board finds the private medical opinions from Dr. Winegar, dated in January 2014 and June 2019, speculative as they appear to be based upon the Veteran’s lay statements, which have been shown to be unreliable. To this end, the Board notes that Dr. Winegar did not address the absence of complaints or treatment for low back pain following the Veteran’s in-service injury. In addition, Dr. Winegar did not discuss the Veteran’s initial report that his back pain manifested after he wrestled with a friend, or the significance, if any, that the Veteran initially reported an in-service back injury in March 2008, approximately eight years after the Veteran was discharged military service. Moreover, there is no indication that Dr. Winegar reviewed the Veteran’s STRs prior to proffering his medical opinions. In this regard, although Dr. Winegar reported that the June 2019 medical opinion was based on a review of all of the evidence in the Veteran’s history, he relied on the Veteran’s statements regarding his initial injury and did not reference any objective medical evidence, other than his own treatment records. See January 2014 Medical Treatment Record – Non-Government Facility; July 2019 Medical Treatment Record – Non-Government Facility; November 2019 CAPRI. Thus, the Board finds that Dr. Winegar’s January 2014 and June 2019 medical opinions are based, at least in part, on an incomplete and inaccurate factual premise, and as such, are currently inadequate to adjudicate the issue on appeal. See Reonal v. Brown, 5 Vet. 458, 461 (1993) (medical opinions based on an incomplete or inaccurate factual premise are not probative). The Board finds that the January 2014 and June 2016 VA addendum opinion, when considered together, probative, as they are factually supported, consistent with the other evidence of record, and included review of the claims file and relevant medical literature. This medical evidence is competent, credible and persuasive, as the opinions are based on accurate facts and supported by a rationale based on medical principles. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, the Board finds that the second and third Shedden requirements have not been met. Although the Veteran is entitled to the benefit-of-the-doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for service connection for a low back disability. The claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Justis, Attorney-Advisor The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.