Citation Nr: 21065393 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 17-23 059 DATE: October 26, 2021 ORDER An initial compensable rating for left ring finger is denied. Service connection for a right thumb disability denied. Service connection for a right index disability is denied. Service connection for a low back disability is granted. Service connection for a right great toe and right foot condition is denied. Service connection for dermatitis is denied. FINDINGS OF FACTS 1. The Veteran is in receipt of the maximum schedular rating for limitation of motion for fracture of the DIP joint and arthritis in the left ring finger. 2. The preponderance of the evidence is against finding that a right thumb disability began during active service, or is otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that a right index finger disability began during active service, or is otherwise related to an in-service injury or disease. 4. The Veteran's has experienced lumbar spine pain and associated symptoms related to the current diagnosis of degenerative arthritis since from service separation. 5. The Veteran's current right great toe and foot condition was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 6. The preponderance of the evidence is against finding that a skin condition to include dermatitis began during active service, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for a higher (compensable) rating for fracture of the DIP joint and arthritis in the left ring finger are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code 5010-5230. 2. The criteria for service connection for a right thumb disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a right index finger disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a low back disability are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 5. The criteria for service connection for a right great toe and right foot condition are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for a skin condition are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1973 to May 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in April 2014 by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Board remanded these matters in October 2019. That remand also included the issue of service connection for headaches. An August 2020 rating decision granted service connection for that issue. As such, it is no longer on appeal before the Board. 1. Entitlement to an initial compensable rating for left ring finger The Veteran contends that her service-connected residuals from fracture of the left ring finger and is entitled to compensable evaluations due to painful motion, weakness, and decreased range of motion. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. See 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.21. Disability evaluations are based upon 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. Separate diagnostic codes identify the various disabilities. See 38 C.F.R. § 4.27. VA has a duty to acknowledge and to consider all regulations that are potentially applicable to issues raised in the record and to explain the reasons and bases for its conclusions. See Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is the primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether they were raised by the Veteran, as well as the entire history of the Veteran's disability. See 38 C.F.R. § 4.1, 4.2; Schafrath,1 Vet. App. at 595. Separate evaluations may be assigned for separate periods of time, or staged, where factual findings show distinct time periods during which the Veteran's disability exhibits symptoms that warrant the application of different ratings. See Fenderson v. West, 12 Vet. App. 119, 126-28 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Additionally, the evaluation of the same disability under several Diagnostic Codes, known as pyramiding, must be avoided. 38 C.F.R. § 4.14. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. See id. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. See id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. See id. The factors involved in evaluating and rating disabilities of the joints include the following: less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); weakened movement (due to muscle injury, disease, or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination and impaired ability to execute skilled movements smoothly; or pain on movement, swelling, deformity, or atrophy of disuse. See 38 C.F.R. § 4.45. Functional loss caused by pain must be rated at the same level as if that functional loss were caused by some other factor that actually limited motion, such as deformity, atrophy, adhesions, or any of the other factors cited above. See Schafrath, 1 Vet. App. at 592. Consequently, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See id. Where the veteran is diagnosed with any form of arthritis, painful motion is an important factor of disability, and facial expressions such as wincing exhibited in the presence of pressure on or manipulation of the affected joints, should be carefully noted and related to the affected joints. See 38 C.F.R. § 4.59. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. See id. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See id. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. See id. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weightbearing and, if possible, with the range of the opposite undamaged joint. See id. When adjudicating disabilities evaluated based upon limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45 pertaining to functional impairment. See DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). In applying these regulations, VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, or incoordination. See id. Such inquiry should not be limited to muscles or nerves, and, if feasible, these determinations should be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. See id. Consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis; thus, a rating based on painful motion of a joint may be appropriate regardless of whether the painful motion stemmed from joint or periarticular pathology. See Burton v. Shinseki, 25 Vet. App. 1, 4-5 (2011). However, pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Although pain may cause functional loss, pain itself does not constitute functional loss and is merely one factor to be considered when evaluating functional impairment; however, 38 C.F.R. § 4.40 does not require a separate rating for pain, but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194, 196 (1997). As stated above, the Veteran contends that his service-connected residuals of fracture of the fourth DIP joint of the left hand (ring finger) is entitled to an initial compensable evaluation due to painful motion, weakness, and decreased range of motion. Additionally, the Veteran's representative noted that x-rays showed arthritis. See 9/14/2021 Appellate Brief. However, after careful review, the Board finds that an increased evaluation under Diagnostic Code 5230 is not supported by current VA regulations, as the maximum evaluation available under Diagnostic Code 5230 is 0 percent, and no other diagnostic codes are applicable in this case. Disabilities of the hand and ring finger are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5227 and 5230. For these diagnostic codes, no distinction is made between major (dominant) and minor (non-dominant) musculoskeletal groups. See 38 C.F.R. § 4.69. Diagnostic Code 5227 provides a noncompensable evaluation for favorable or unfavorable ankylosis of the ring finger and further requires consideration as to whether amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. Diagnostic Code 5230 provides a noncompensable evaluation for any limitation of motion of the ring finger. Traumatic arthritis is governed by Diagnostic Code 5010, which provides that arthritis that is due to trauma and substantiated by X-ray findings must be evaluated as degenerative arthritis. Degenerative arthritis is governed by Diagnostic Code 5003, which provides that arthritis must be established by X-ray findings and must be evaluated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. In the absence of limitation of motion, X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, will warrant a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5003. X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups will warrant a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The 10 percent and 20 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note 1. Effective February 7, 2021, DC 5010 provides that traumatic arthritis is now to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. A December 2013 VA hand Disability Benefits Questionnaire (DBQ) shows that the Veteran was diagnosed with a fracture DIP joint and posttraumatic arthritis left ring finger. The Veteran reported no pain but limited range of motion. The Veteran did not report flare ups. Limited range of motion and painful motion of the ringer finger were noted. A gap between any fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips with a gap of less than 1 inch. Repetitive use testing was conducted with additional loss of range of motion was noted. Ring finger function impairment was noted as less movement than normal, incoordination and impaired ability to execute skilled movements smoothly, pain on movement, and deformity. Hand strength was 5/5. Ankylosis of the ring finger was assessed on the distal joint. The examiner noted that the condition did not impair the overall function of the hand. The Veteran was noted to use a brace. The examiner reported that the finger condition did not result in functional impairment that no effective function other than that would be equally well served by an amputation with prosthesis. The examiner reported that the ring finger disability impacted the Veteran's ability to work as he had to take breaks for 20 minutes about every hour. A December 2019 VA hand and finger DBQ shows the Veteran was diagnosed with arthritis in the left ringer finger and fracture DIP joint. The Veteran reported current symptoms of hand pain with frequent use, dull aching pain, and dropping items. Flare ups were reported that were moderate to severe that lasted anywhere from a few hours to a couple of days. Left ring finger range of motion noted extension to 0 degrees from MCP, PIP, and DIP were to 0 degrees. Max flexion of the MCP and PIP joint were 90 degrees and DIP joint was 50 degrees. No gap between the thumb and fingers were assessed. Pain with use of the hand and tenderness to palpation of the soft tissue of the DIP joint of the left ring finger was assessed. Repetitive use testing was conducted with no additional loss of range of motion. Pain and fatigue were noted to limit functional ability with repeated use over a period of time and during flare ups. Muscle strength testing was 5/5 for the left hand. Ankylosis was not assessed. Left hand showed no objective evidence of pain on non-weight bearing was assessed. Passive range of motion was noted as the same of active range of motion results. Impacts on working were noted as difficulty with gripping, carrying, pulling, lifting items as well as typing, and writing. Stiffness was also assessed. In this case, as stated above, the Veteran's service-connected fracture residuals of the left DIP joint has been assigned a noncompensable evaluations under Diagnostic Code 5010-5230 for limitation of motion. However, after careful review, the Board finds that an increased evaluation under Diagnostic Code 5010-5230 is not warranted under current VA regulations, as the maximum evaluation available under Diagnostic Code 5230 is 0 percent for any limitation of motion. The Board has considered whether a higher evaluation based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint is warranted in this case, and notes that the record contains multiple, consistent lay statements from the Veteran describing the painful motion, weakness, and limited range of motion of his left finger, to include her consistent statements to VA medical treatment providers and during the VA examination reports of record. Moreover, the Board finds that the Veteran is competent to describe the observable, non-medical symptoms of his left ring finger disability, such as the nature, severity, and location of his pain, weakness, and limited range of motion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, the Veteran's lay statements regarding her left ring finger symptoms are credible because such statements have been consistent with each other and throughout the evidence of record. The evidence shows that the Veteran has arthritis in his left hand, based on imaging studies. See December 2013 and 2019 VA examinations. Under DC 5003, degenerative arthritis established by X-ray finding will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involves is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints. The hand is considered a group of minor joints. 38 C.F.R. § 4.45. Limitation of motion in a "group of minor joints" requires more than one minor joint suffering from limitation of motion to qualify for the 10 percent rating contemplated by DC 5003. Spicer v. Shinseki, 752 F.3d 1367, 1371 (Fed. Cir. 2014). In this case, the evidence shows limitation of motion only on the left ring finger. Further, the evidence of record, including the December 2019 VA examination report, shows that only the distal interphalangeal joint of the Veteran's left ring finger is affected by arthritic changes. As the evidence does not show more than one minor joint suffering from limitation of motion, a 10 percent rating under DC 5003 is not warranted. The Board acknowledges that, under 38 C.F.R. § 4.59, painful joints are entitled to at least the minimum compensable rating for the joint. As stated above, the Diagnostic Codes applicable to the Veteran's left ring finger disability are Diagnostic Codes 5227 and 5230; both of which provide for a single noncompensable rating. As such, a minimum compensable rating for painful motion is not available for the Veteran's left ring finger as a matter of law. See Sowers v. McDonald, 27 Vet. App. 472, 480 (2016) (holding that because there is no minimum compensable rating available under DC 5230 and because the intent of 38 C.F.R. § 4.59 is to compensate painful motion with at least the minimum compensable rating, those regulations read together do not entitle a claimant to a compensable rating under DC 5230). The Board has also considered whether the Veteran's service-connected fracture residuals of the fourth DIP joint of the left hand warrant the assignment of any additional disability ratings under other diagnostic codes at any point during the period on appeal. See Schafrath, 1 Vet. App. at 595. However, the Board finds no basis upon which to assign increased or additional ratings for the Veteran's left hand disability at any point during any period of appeal, as the Veteran's left ring finger have never been found to manifest favorable or unfavorable ankylosis. See 38 C.F.R. § 4.71a, Diagnostic Code 5227. In addition, the evidence of record, including the VA examination reports of record, do not indicate that the amputation of the Veteran's left ring or little finger would be warranted in this case. See 38 C.F.R. § 4.71a, Diagnostic Code 5227, Note. In sum, the Board finds that compensable evaluations for the Veteran's service-connected right fourth and fifth residual fractures are not warranted at any time during the period on appeal, as a noncompensable evaluation is the maximum award available for limitation of motion of the left ring finger under Diagnostic Code 5230, and no other diagnostic codes are applicable in this case. See 38 C.F.R. § 4.71a, Diagnostic Codes 5227, 5230. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. That determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). Service connection may be presumed for certain chronic diseases, to include arthritis, which develop to a compensable degree within one year after discharge from service, even though there is no evidence of such disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. § 3.307, 3.309(a). Where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has that chronic disability, service connection can be granted. That does not mean that any manifestations in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease entity is established, there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing a service connection claim. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was noted during service; (2) evidence of post- service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. Continuity of symptomatology applies only to those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 2. Entitlement to service connection for a right thumb disability 3. Entitlement to service connection for a right index disability The Veteran contends that she injured her right index finger and thumb during active service and that since separation from service she continued to experience right index finger and thumb pain. The Board finds that while the Veteran has a diagnosis of tenosynovitis of right index finger and thumb (see, e.g., December 2019 VA examination report), the preponderance of the evidence is against finding that currently diagnosed disabilities are related to the in-service complaints and treatments for a right index finger and thumb injuries. A December 2019 VA hand and finger Disability Benefits Questionnaire (DBQ) shows that after a review of the evidence of record to include an examination of the Veteran, the examiner remarked that the right thumb disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner reported that the Veteran was not noted to have a complaint or prior history of right index finger and thumb condition or pain noted on enlistment exam on March 1973. The Veteran was treated for a jammed right thumb and x-rays taken on November 1974 were negative. The examiner noted that the Veteran was treated for right index finger and thumb pain in June 1983 and diagnosed with tendonitis. X-rays taken in June 1983 were noted to be negative. The Veteran was also noted to be treated with a steroid injection into base of right thumb in August 1983 which she stated good relief and full range of motion. The examiner noted that the Veteran's retirement examination in February 1992 showed no complaints or a prior history of a right thumb condition. The examiner noted that the Veteran did have slight decreased ROM on physical exam today but given the Veteran's medical records and findings on exam today, a chronic right thumb condition that was either caused or incurred during active military service was not established. Therefore, the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner reported that the right index fingers and thumb were acute in nature. The examiner also cited to medical literature to support the opinion. After a review of the evidence of record the Board finds that the preponderance of the evidence is against the Veteran's claims for service connection. Initially, the Board notes that although the Veteran was treated for right index finger and thumb tendonitis during service and diagnosed with right thumb tendonitis in 2019, the evidence does not support a nexus between the two diagnosis. Here, the Veteran was last assessed with right index finger and thumb tendonitis during service in 1983 but during the remaining 10 years the Veteran's served she was not diagnosed nor did she report further right finger or thumb pain. Additionally, there are no reports or treatment of a right index finger or thumb condition until 2012 which is 19 years after she separative from service. Moreover, during the December 1992 separation examination she was clinically assessed with a normal right index finger or thumb and did not self-report any right index finger or thumb condition upon physical examination of that time. It is notable that the Veteran did report other conditions on separation from service such as a neck condition, left ankle condition, and left finger condition. Accordingly, it is reasonable to expect that there would be some notation of complaints pertaining to the right index finger or thumb on separation from service had such problems manifested at that time, as the Veteran reported other musculoskeletal conditions. This tends to show that if musculoskeletal complaints were present they would have been reported to appropriate medical personnel. However, with the exception of the 1983 service treatment records showing treatment for a right index finger and thumb condition, there were no other reports or treatment for a right index finger or thumb condition. The evidence tends to show that the Veteran was first assessed after separation from service with a right index finger and thumb condition many years after separation from active service. The Board finds this as evidence that tends to weight against the claim when viewed in light of the Veteran's medical history. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (stating that while a gap in time is not automatically a factor that weighs against a claim, it can be considered, but only along with all the evidence). Additionally, the Board finds that the VA examiner's opinion in this case is persuasive and based upon adequate rationale. The VA examiner is shown to have reviewed the evidence then of record and to have adequately considered the credible lay statements and reported symptom manifestation history of record and determined that the right index finger and thumb conditions are not related to active service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007).The VA examiner conducted a thorough review of the record and provided a supporting rationale. Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (holding that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). The only evidence in support of the Veteran's contention that her right index finger and thumb conditions are related to active service are her own lay statements. While the Veteran may be credible to describe the particular symptoms which she experiences, determining the exact nature and diagnosis of the right index finger and thumb whether the disability was caused by drilling and exercises during active, requires specialized testing and medical knowledge or training regarding the musculoskeletal systems which the Veteran is not shown to have. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, the Veteran is not competent to provide an etiology opinion regarding her right index finger and thumb conditions and any statements in this regard lack weight. In conclusion, the Board finds that service connection for a right index finger and thumb conditions is not warranted. When all the evidence is assembled, VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). As described above, the preponderance of the evidence is against service connection for right index finger and thumb disabilities. 4. Entitlement to service connection for a low back disability The Veteran contends that she injured low back during active service and that since separation from service she has continued to experience low back pain. The Board finds that while the Veteran has a current diagnosis of a low back disability noted as degenerative disc disease and degenerative joint disease per the December 2019 VA spine examination. Arthritis is an enumerated chronic condition under 38 C.F.R. § 3.309(a). Regarding in-service event or injury, the Veteran was treated for low back pain in May 1975, 1977, January 1978, June 1980, and April and July 1981. The February 1992 separation examination clinically assessed her with a normal spine and she did not self-report any low back condition upon physical examination of that time. Regarding nexus, a December 2019 VA back DBQ, show that the VA examiner remarked that the low back disability diagnosed as degenerative joint disease and degenerative disc disease were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran did not have any complaints or prior history of back pain or condition noted on enlistment exam in March 1973. The examiner noted that the Veteran was seen in clinic with complaint of back pain and diagnosed with muscle strains in May 1976 and June 1980. The Veteran was noted to have back strain improving from clinic note from June 1980. The examiner noted that the Veteran had normal physical exams on October 1989 and October 1990 with no complaints of back pain. The examiner reported that Veteran had no complaints or prior history of back pain mention on retirement exam done in February 1992. The examiner noted that x-rays completed in 2013 showed degenerative disc and spine changes in the lumbar spine which was done over 20 years after separation from active service. The examiner remarked that given the veteran's medical history as well as findings on physical exam and diagnostic imaging, a chronic back condition that was either caused or incurred during military service was not shown. Therefore, the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner further reported that the Veteran did have recurrent lumbar muscle strains and low back strains documented from May1975 through 1993. The examiner remarked that each lumbar related strain was noted to be acute in nature. No chronic diagnosis was afforded due to the low back pain resolving after each incident. The examiner referenced that an x-ray of the lumbar spine showed degenerative changes throughout the spine dated August 2013. Degenerative disc disease was reported by the examiner as a multifaceted progressive irreversible condition and an inevitable part of aging, which has been found to be a contributing factor for low back pain and might cause radiculopathy, myelopathy, spinal stenosis, degenerative spondylolisthesis, and herniations. Due to the Veteran's x-ray findings, the examiner opined that the current low back disorder of the lumbar degenerative joint disease are less likely than not (less than 50 percent probability) related to the Veteran's various reports and treatments for low back strains that occurred during service and her reported of experiencing low back in 1993. The examiner referenced medical literature to support the opinion. After carefully reviewing and weighing the competent medical and lay evidence of record, the Board is satisfied that it is in at least approximate balance as to whether the Veteran's current cervical spine arthritis is related to service. The 2019 negative nexus VA opinion is acknowledged. However, the 2019 VA examiner did not address the Veteran's statements of continued pain. Her statements and testimony are credible and entitled to probative weight, as they are internally consistent and consistent with other evidence of record, which shows that she first complained of lumbar pain in service and the symptoms continue with his current degrative spine arthritis. Based on the foregoing, the Board finds that the Veteran's symptoms began during a period of active service and have continued since that time. She has since been diagnosed with arthritis, which is considered a chronic disease for VA compensation purposes. Although arthritis was not objectively demonstrated during active service or within one thereafter, service connection may be granted based on continuity of symptomatology. 38 C.F.R. §§ 3.30(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Therefore, the Board finds that service connection is warranted for the Veteran's lumbar spine arthritis. 5. Entitlement to service connection for a right great toe and right foot condition The Veteran asserts that her right great toe and foot condition were caused by active service. The Board finds that while the Veteran has a diagnosis of a right great toe and right foot condition ,the preponderance of the evidence is against finding that currently diagnosed disabilities are related to the in-service complaints and treatments for right great toe and foot injuries. A December 2019 VA foot DBQ shows that the Veteran was diagnosed with hallux valgus and hallux rigidus. The Veteran reported having lots of foot pain in service as she was doing a lot of training and drilling in uncomfortable combat boots. Pain and stiffness of the right big toes was noted. After a review of the evidence of record and a physical examination of the Veteran the examiner opined that the right hallux valgus, hallux rigidus, and right toe fracture with surgery were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner reported that the Veteran was not noted to have any complaints or a prior history of right foot condition on enlistment exam in 1973. The examiner noted that the Veteran was diagnosed with right foot sprain in October 1975 with negative x-rays. The Veteran was also noted to be diagnosed with hematoma of right great toe in September 1978. A jammed right great toe was noted and diagnosed with soft tissue trauma on October 1979 with negative x-rays. The examiner reported that the Veteran had normal physical exams in October 1989 and October 1990 with no complaints of right foot or toe pain. Additionally, the examiner noted that the Veteran had no complaints or prior history of right foot or toe pain noted on retirement exam on February 1992. Given that there was no complaint or deformity of right foot or great toe noted on separation exam and x-rays done at time of complaints during service were reported as normal, the examiner remarked that they were unable to establish a chronic right foot/toe condition that was either caused or incurred by active military service. Therefore, the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner remarked that hallux valgus was a common foot problem whose cause and progression is multifactorial, complex, and poorly known. Hallux valgus was reported to have a predilection toward women. The examiner reported it was a progressive disorder with no treatment known to slow or stop progression. The examiner reported that of all patients aged over 50 years, 2.5% report degenerative arthritis of the first metatarsophalangeal (MTP) joint, termed 'hallux rigidus'. First MTP osteoarthritis was reported as the most common arthritic condition in the foot. Progression of great toe arthritis is associated with pain and loss of motion. Hallux rigidus and Hallux valgus are progressive degenerative disorders that occur over time. The 1978 and 1979 right great toe and right foot conditions were acute in nature and thus the examiner further opined that the Veterans current right great toe/foot disorders, were less likely than not (less than 50 percent probability) related to active service io include in service treatment for foot pain. Based upon the evidence of record, the Board finds that the competent and probative evidence tends to weigh against a finding that the current right great toe and foot condition was manifest during active service or caused by active service. The evidence demonstrates that the Veteran was first assessed with a right great toe and foot condition may years after separation from active service. Additionally, the Board finds that the VA examiner's opinion in this case is persuasive and based upon adequate rationale. The VA examiner is shown to have reviewed the evidence then of record and to have adequately considered the credible lay statements and reported symptom manifestation history of record and determined that the right great toe and foot condition is not related to active service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007).The VA examiner conducted a thorough review of the record and provided a supporting rationale. Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (holding that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). The only evidence in support of the Veteran's contention that her right great toe and foot condition is related to active service. While the Veteran may be credible to describe the particular symptoms which she experiences, determining the exact nature and diagnosis of the right great toe and foot condition and whether the disability was caused by drilling and exercises during active, requires specialized testing and medical knowledge or training regarding the musculoskeletal systems which she is not shown to have. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, the Veteran is not competent to provide an etiology opinion regarding her right great toe and foot condition and her statements in the regard lack weight. In conclusion, the Board finds that service connection for a right great toe and foot condition is not warranted. When all the evidence is assembled, VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). As described above, the preponderance of the evidence is against service for right great toe and foot condition. 6. Entitlement to service connection for dermatitis The Veteran asserts that her skin condition onset during active service. The Board finds that while the Veteran has a diagnosis of a skin condition, to include contact dermatitis per the December 2019 VA examination. However, the preponderance of the evidence is against finding that currently diagnosed skin condition is related to the in-service complaints and treatments various skin conditions. A January 2020 VA skin DBQ shows that after a review of the claims file and examination of the Veteran, the examiner opined that the skin condition of dermatitis was less likely than not (less than 50 percent probability) incurred in or caused by the skin conditions noted during service. The examiner remarked that the Veteran was noted to have probably diagnosis of pityriasis rosea (triggered by viral infection) in January 1975 and was also seen in July 1975 for bee sting and was noted to have allergic reaction to Timeral in 1974. The examiner also noted that the Veteran was diagnosed with allergic dermatitis versus scabies as evident by rash she had on September 1979. Contact dermatitis was also assessed in September 1992, but the examiner noted that on retirement exam done in February 1992, the Veteran self-reported no skin conditions and was clinically assessed with normal skin. The examiner reported that during the December 2019 examination the Veteran reported coming into contact with things in service such as poison ivy, oak, bee stings and medications like Timeral that caused her to break out in rashes. The examiner reported that these reactions were suggestive of contact dermatitis and the condition usually resolved when the irritant was removed. The examiner explained that these irritants would likely cause skin irritation to most people that come into contact with them regardless of military service. The examiner reported that the given the Veteran's health history as well as findings on exam today, chronic skin condition that was either caused or incurred during military service could not be established. The examiner also added that Pityriasis rosea is thought to be a pruritic viral rash that is self-limiting. Pityriasis Rosea presents with a trademark "Herald Patch" on the skin. The service treatment records were noted as silent for the appropriate presentation of Pityriasis rosea in January 1975. The Veteran was treated with Calamine lotion and advised to follow up to the clinic as needed. A review of the STR is silent for additional followup treatments for this condition. Allergic contact dermatitis is a pruritic self-limiting condition that typically resolves after the inciting allergen is removed. The veteran was diagnosed with allergic dermatitis versus scabies in August of 1979. Scabies is a human parasite transmitted by direct person-to-person contact or through objects that carry the mites, such as clothing and bedding. The Veteran was treated with hydrocortisone cream and Atarax tablets. A review of the service treatment records were silent for additional follow up treatments for allergic dermatitis or scabies. Thus, the examiner opined that the Veteran's current dermatitis diagnosis is less likely than not due to or the result of the veteran's in-service treatment for pityriasis rosea rendered in January 1975 or her treatment for allergic dermatitis versus scabies in August 1979. Based upon the evidence of record, the Board finds that the current skin condition was not manifest during active service or caused by skin conditions noted during active service. The evidence demonstrates that the Veteran was first assessed dermitis many years after separation from active service. Additionally, the Board finds that the VA examiner's opinion in this case is persuasive and based upon adequate rationale. The VA examiner is shown to have reviewed the evidence then of record and to have adequately considered the credible lay statements and reported symptom manifestation history of record and determined that the current skin condition is not related to active service or treatments for various skin condition noted throughout her active service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007).The VA examiner conducted a thorough review of the record and provided a supporting rationale. Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (holding that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). The evidence in support of the claim includes the Veteran's statements that her skin condition is related to active service. While the Veteran may be credible to describe the particular symptoms which she experiences, determining the exact nature and diagnosis of the skin condition and whether the disability was caused in-service treatments for skin condition to include pityriasis rosea, poison ivy, poison oak, and bee stings requires specialized testing and medical knowledge or training regarding the skin organ which the Veteran is not shown to have. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, the Veteran is not competent to provide an etiology opinion regarding her current diagnose skin condition and her statements in this regard lack weight. Additionally, an applicable VA regulation does not support a grant here. The regulation states that seasonal and other acute allergic manifestations subsiding on the absence of or removal of the allergen are generally to be regarded as acute diseases, healing without residuals. The determination as to service incurrence or aggravation must be on the whole evidentiary showing. 38 C.F.R. § 3.380 (2020). Applying the facts here, the 2019 VA examination report shows a diagnosis of contact dermatitis. This would lead to the conclusion that once contact with the irritating substance/allergen, such as poison ivy/oak or bee sting, is removed then the skin irritation subsides. The 2019 VA examination examiner indicated that the Veteran was treated with medication and lacked follow up visit tend to show that the skin problem resolved. (Continued on the next page) In conclusion, the Board finds that service connection for a skin condition is not warranted. When all the evidence is assembled, VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). As described above, the preponderance of the evidence is against this appeal. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dworkin, Counsel 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.