Citation Nr: 21071780 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 18-48 332 DATE: December 1, 2021 ORDER Entitlement to a rating in excess of 70 percent for status post craniotomy, with adjustment disorder, mixed anxiety and depressed mood, is denied. Entitlement to an initial rating in excess of 50 percent for post craniotomy headaches, secondary to service-connected status post craniotomy, with adjustment disorder, mixed anxiety and depressed mood, is denied. Entitlement to a rating in excess of 20 percent for seizure disorder is denied. Entitlement to service connection for a disability manifested by pain in the right hand is denied. Entitlement to service connection for a disability manifested by pain in the left hand is denied. Entitlement to service connection for a disability manifested by a right hip condition is denied. Entitlement to service connection for a disability manifested by shin pain is denied. FINDINGS OF FACT 1. The Veteran's status post craniotomy symptoms associated with adjustment disorder, mixed anxiety and depressed mood, have not approximated total occupational and social impairment at any point during the pendency of this appeal. 2. For the entire period on appeal, the Veteran's service-connected post craniotomy headaches, secondary to service-connected status post craniotomy, with adjustment disorder, mixed anxiety and depressed mood, have been assigned a 50 percent rating, which is the maximum schedular rating authorized for headaches under Diagnostic Code 8100. 3. For the entire appeal period the seizure disorder is not shown to be productive of at least one major seizure in the last 6 months or 2 in the last year; or averaging at least 5 to 8 minor seizures weekly. 4. A disability manifested by pain in the right hand did not manifest during service, is not etiologically related to service, and is not secondary to a service-connected disability. 5. A disability manifested by pain in the left hand did not manifest during service, is not etiologically related to service, and is not secondary to a service-connected disability. 6. A disability manifested by a right hip condition did not manifest during service, is not etiologically related to service, and is not secondary to a service-connected disability. 7. A disability manifested by shin pain did not manifest during service, is not etiologically related to service, and is not secondary to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 70 percent for status post craniotomy, with adjustment disorder, mixed anxiety and depressed mood are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7; 4.124a, Diagnostic Code 8003; 4.126a; 4.130, Diagnostic Code 9326. 2. For the entire period on appeal, the criteria in excess of an initial rating higher than 50 percent for post craniotomy headaches, secondary to service-connected status post craniotomy, with adjustment disorder, mixed anxiety and depressed mood, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.7, 4.124a Diagnostic Code 8100. 3. For the entire appeal period, the criteria in excess of a rating higher than 20 percent for the seizure disorder, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.7, 38 C.F.R. § 4.124a Diagnostic Code 8911. 4. A disability manifested by pain in the right hand did not manifest during service, is unrelated to service, and was not caused or aggravated by a service-connected disability. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. A disability manifested by pain in the left hand did not manifest during service, is unrelated to service, and was not caused or aggravated by a service-connected disability. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. A disability manifested by a right hip condition did not manifest during service, is unrelated to service, and was not caused or aggravated by a service-connected disability. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 7. A disability manifested by shin pain did not manifest during service, is unrelated to service, and was not caused or aggravated by a service-connected disability. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1995 to February 2000. The Board notes that VA treatment records in October 2014 indicate that the Veteran was applying for benefits from the Social Security Administration (SSA). However, as the evidence does not show nor does the Veteran contend that there are relevant SSA records that need to be obtained regarding the issue currently before the Board, a remand is not warranted to obtain SSA records. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2009). The Board also notes that on VA examination for mental disorders in April 2021 the Veteran reported that for 6 years she did not work due to her brain surgery and started working again in 2016. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim for a total disability rating for individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. However, in the instant case the evidence does not show nor does the Veteran contend that she has not been able to maintain substantially gainful employment due to her service-connected disabilities and thus the issue of TDIU has not been raised by the record and is not currently before the Board. The Board also notes that the Veteran's representative in a June 2021 brief included the issues of entitlement to service connection for alopecia, back strain, right ankle strain, sinusitis, fatigue, loss of taste, and left ear hearing loss. However these issues are not in appellate status as the Board in the November 2020 decision denied entitlement to service connection for sinusitis and denied reopening the service connection claim for left ear hearing loss. In a rating decision in January 2021 the Agency of Original Jurisdiction granted service connection for thoracolumbar spine strain, right ankle strain, alopecia, extreme fatigue, and loss of taste to include hypogeusia. Thus, these claims are no longer in appellate status. Lastly, in June 2021 the Veteran was advised that the Veterans Law Judge who conducted the Board hearing in February 2020 is no longer employed by the Board. She was given 30 days to respond as to whether she desired another Board hearing. The Veteran did not reply and thus it will be assumed she does not want a new Board hearing. Increased Ratings A disability rating is 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 their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Issues 1: Entitlement to a rating in excess of 70 percent for status post craniotomy, with adjustment disorder, mixed anxiety and depressed mood (hereinafter status post craniotomy). The Veteran's service-connected status post craniotomy has been rated 70 percent disabling under Diagnostic Codes 8003-9326. Diagnostic Code 8003 provides a minimum 60 percent rating for benign new growth in the brain, and residuals are rated according to the appropriate rating criteria, with a minimum rating of 10 percent. 38 C.F.R. § 4.124a, Diagnostic Code 8003. Diagnostic Code 9326 for major or mild neurocognitive disorder due to another medical condition or substance/medication-induced major or mild neurocognitive disorder is part of the General Rating Formula for Mental Disorders. Under these criteria a 70 percent rating is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). The Board notes, with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), that ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The United States Court of Appeals for the Federal Circuit emphasized that the list of symptoms under a given rating is a nonexhaustive list, as indicated by the words "such as" that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). It held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. VA must consider all symptoms of a claimant's condition affecting the level of occupational and social impairment, including, if applicable, those identified in the Diagnostic and Statistical Manual of Mental Disorders (DSM). When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). It is the impact of the symptoms on occupational and social functioning that determines the rating. By way of history the Veteran's intent to file an increased rating claim for her status post craniotomy was received in May 2017 and the formal claim was received in November 2017. During the appeal period the pertinent findings show that on VA examination for mental disorders in February 2018, the examiner opined that the Veteran had occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. The examiner indicated that during the appeal period the Veteran has worked since 2016 but has not been able to work more than 6 weeks since her surgery for a hysterectomy in December 2017. She works in administrative support and was due to go back to work on February 14, 2018. Symptoms included depressed mood; anxiety; panic attacks more than once a week; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, direction or recent events; impairment of short and longer-term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect, impaired abstract thinking; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. During the examination the Veteran's grooming was normal but she reported that there can be weeks she did not take care of her hygiene. The examiner noted that the Veteran was currently out on disability but has to go back to work in February 2018. The Veteran reported irritability. VA treatment records include in August 2019 show that the Veteran was oriented to person, place, and time. VA treatment records in September 2019 show that the Veteran was working at the IRS. She reported that she was working hard to "get myself together for my nephew and nieces," adding that since her brother, the children's father passed away last year, she felt a great sense of responsibility to care for them. On VA examination for mental disorders in April 2021, the examiner opined that the Veteran had occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported socially isolating herself and did not have friends. She reported that she was no longer interacting with her sister. Her irritability negatively impacted her relationships. She also had poor focus, fatigue, and irritability. The Veteran reported that for 6 years she did not work due to her brain surgery and she started working again at the IRS in 2016 as a functional training liaison. She was currently working from home; however, she missed many days due to pain. She reported her performance has been fair. Symptoms included depressed mood; anxiety; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, direction or recent events; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; and inability to establish and maintain effective relationships. During the examination the Veteran was casually dressed and had adequate hygiene. The above findings are uncontroverted by the other competent evidence of record. The evidence of record does not more nearly approximate the criteria for a 100 percent rating for total occupational and social impairment for the following reasons. The VA examinations of record at most assessed the Veteran's symptoms as causing occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In order to meet the criteria for a 100 percent rating for PTSD, there must be both total occupational and social impairment. While the Board recognizes that the Veteran reported having no friends and a strained relationship with her sister, the evidence also shows that she cared for her nephew and nieces. See September 2019 VA treatment record. Further, the Veteran has been gainfully employed throughout the appeal period. Such evidence belies a finding of total occupational and social impairment. Accordingly, the Board finds that the Veteran's impairment due to her status post craniotomy is most consistent with a 70 percent rating for the entire appeal period. Thus, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b) Issue 2: Entitlement to an initial rating in excess of 50 percent for post craniotomy headaches, secondary to service-connected status post craniotomy, with adjustment disorder, mixed anxiety and depressed mood (hereinafter headaches). The Veteran's service-connected headaches are rated 50 percent disabling under Diagnostic Code 8100. Under Diagnostic Code 8100, a noncompensable rating is warranted for less frequent migraine attacks. A 10 percent rating is warranted for characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent rating is warranted for characteristic prostrating attacks occurring on an average once a month over the last several months. Finally, a maximum 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. In determining whether the Veteran experiences the type and frequency of prostrating attacks of migraine headaches necessary for a higher rating under Diagnostic Code 8100, the Board observes that the rating criteria do not define "prostrating," nor has the United States Court of Appeals for Veterans Claims (Court). Cf. Fenderson v. West, 12 Vet. App. 119 (1999). By way of reference, the Board notes that, according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." The terms "productive of severe economic adaptability" have not been clearly defined by regulations or case law. The Court has noted that "productive of" can either have the meaning of "producing" or "capable of producing." Pierce v. Principi, 18 Vet. App. 440, 445 (2004). Migraines need not actually "produce" severe economic inadaptability to warrant the 50 percent rating. Id. at 445-46. "Economic inadaptability" does not mean unemployability, as such would undermine the purpose of regulations pertaining to a total disability rating based on individual unemployability. Id. at 446; 38 C.F.R. § 4.16. At a minimum, however, migraines must be capable of producing "severe" economic inadaptability. The rating criteria under Diagnostic Code 8100 are successive, meaning that to satisfy the criteria for a higher level, a claimant must satisfy all the requirements of the lower levels, and 38 C.F.R. §§ 4.7 and 4.21 do not apply to circumvent these requirements. Johnson v. Wilkie, 30 Vet. App. 245 (2018). By way of history, the Regional Office (RO) in a March 2018 rating decision granted service connection for post-craniotomy headaches and assigned a 50 percent rating effective May 9, 2017, the date the Veteran's intent to file a claim was received. On VA headaches examination in February 2018, the examiner opined that the Veteran had characteristic prostrating attacks of migraine/non-migraine headache pain more frequently than once per month and the Veteran's very prostrating and prolonged attacks of migraines/non-migraine pain were productive of severe economic inadaptability. On VA headaches examination in January 2021, the examiner opined that the Veteran had characteristic prostrating attacks of migraine/non-migraine headache pain and the Veteran's very prostrating and prolonged attacks of migraines/non-migraine pain were productive of severe economic inadaptability. As discussed previously, under Diagnostic Code 8100, 50 percent is the highest schedular available rating assigned for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015) ("[W]hen a condition is specifically listed in the Schedule, it may not be rated by analogy."). As there is no legal basis upon which to award a higher schedular evaluation for migraine headaches, the Veteran's appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). Issue 3: Entitlement to a rating in excess of 20 percent for seizure disorder. The Veteran's seizure disorder is rated 20 percent disabling under Diagnostic Code 8911 for petit mal epilepsy. Under Diagnostic Code 8911, both the frequency and type of seizure a veteran experiences are considered in determining the appropriate rating. A major seizure is characterized by generalized tonic-clonic convulsion with unconsciousness. A minor seizure consists of a brief interruption in consciousness or conscious control associated with staring or rhythmic blinking of the eyes or nodding of the head ("pure" petit mal), or sudden jerking movements of the arms, trunk, or head (myoclonic type) or sudden loss of postural control (akinetic type). Diagnostic Code 8911 is part of the General Formula for Major and Minor Epileptic Seizures, which provides that a 10 percent rating is assigned when there is a confirmed diagnosis of epilepsy with a history of seizures. A 20 percent rating is assigned when there has been at least one major seizure in the last two years or at least two minor seizures in the last six months. A 40 percent rating is for application when there is at least one major seizure in the last 6 months or 2 in the last year; or averaging at least 5 to 8 minor seizures weekly. A 60 percent rating is for application when there is an average of at least one major seizure in 4 months over the last year; or 9 to 10 minor seizures per week. An 80 percent evaluation is for application when there is an average of at least one major seizure in 3 months over the last year; or more than 10 minor seizures weekly. A 100 percent evaluation is for application when there is an average of one major seizure per month over the last year. 38 C.F.R. § 4.124a Diagnostic Code 8911. In the presence of major and minor seizures, the predominating type is rated and there is no distinction between diurnal and nocturnal major seizures. Further, under 38 C.F.R. § 4.121, regarding the identification of epilepsy, to warrant a rating the seizures must be witnessed or verified at some time by a physician, and regarding the frequency of epileptiform attacks, competent, consistent lay testimony emphasizing convulsive and immediate post-convulsive characteristics may be accepted. It is also provided that the frequency of seizures should be ascertained under the ordinary conditions of life while not hospitalized. By way of history, the Veteran's claim for a higher rating for a seizure disorder was received in November 2017. The evidence during the appeal period does not more nearly approximate the criteria for a rating higher than 20 percent for seizures as the Veteran did not have at least one major seizure in the last 6 months or 2 in the last year; or averaging at least 5 to 8 minor seizures weekly. On VA examination for seizure disorders in December 2017, the examiner noted that continuous medication was not required for control of seizure activity. The examiner noted that the Veteran's symptoms included episodes of staring or rhythmic blinking of the eyes. The examiner stated that the most recent seizure was on November 1, 2017 and 2 or more minor seizures over the past 6 months, averaging from zero to 4 per week. The examiner indicated that the Veteran has not had major seizures, minor psychotmotor seizures, or major psychomotor seizures. The examiner noted that the Veteran had scarring but the scars were not painful, unstable and did not cover a total area greater than 39 square centimeters (6 square inches). The Veteran reported that she had seizures approximately twice per month. On VA examination for seizure disorders in January 2021, the Veteran reported that her last grand mal seizure was in 2018 and she had a total of 15 mild seizures in the last year. She was on medication. The Veteran's symptoms included brief interruption in consciousness or conscious control. The Veteran reported confusion, incontinence and tongue biting associated with seizures. The examiner determined that the Veteran had 2 or more minor seizures over the past 6 months averaging zero to 4 per week. The examiner indicated that the Veteran has had major seizures but none in the past two years. The average frequency of major seizures was less than 1 in the past 6 months. The examiner noted that the Veteran has not had minor or major psychomotor seizures. The above findings are not controverted by the other competent evidence of record. The evidence does not more nearly approximate the criteria for a rating higher than 20 percent for seizures as the Veteran did not have at least one major seizure in the last 6 months or 2 in the last year; or averaging at least 5 to 8 minor seizures weekly. To the extent that scarring was noted on the December 2017 VA examination, the Veteran is in receipt of a separate rating for a scar on her scalp, which is not currently before the Board. During the February 2020 Board hearing the Veteran testified that she had two or more seizures per week and they have become more intense, to include biting lips and tongue, confusion and body aches, and a lot of hand movements and body movements. The Board has considered the Veteran's statements that describe her seizure disorder. The Veteran is certainly competent to describe her observations and the Board finds that her statements are credible. In this case, however, the objective medical findings by skilled professionals are more persuasive which, as discussed above, do not support a higher rating. In essence, the lay evidence, while accepted as credible, does not provide a basis for a higher evaluation. For these reasons, the preponderance of the evidence is against the claim for a rating in excess of 20 percent for a seizure disorder and the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b). Issues 4-7: Entitlement to service connection for a disability manifested pain in the right hand, pain in the left hand, right hip condition, and shin pain. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). For the showing of 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." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). To grant service connection under any theory of entitlement, there must be a current disability. Degmetich v. Brown, 104 F.3d 1328, 1332 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Absent a diagnosis, a symptom significant enough to result in functional impairment in earning capacity qualifies as a disability. Saunders v. Wilkie, 886 F.3d 1356, 1367-1368 (Fed. Cir. 2018) (concerning the symptom of pain). Service connection may also be granted on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disorder. 38 C.F.R. § 3.310(a). Secondary service connection may be found in certain instances in which a service-connected disability aggravates another condition. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). The Veteran contends that she has bilateral hand pain and right hip pain due to falling as a result of her service-connected craniotomy. See February 2020 Board hearing transcript. She testified that she hurt her shins during service when she hit them with a suitcase. Id. The Veteran also contends that she had shin pain from running and walking. See September 2000 claim. Service treatment records show that in March 1995 the Veteran was seen for general pain including leg pain. The records show that all work-up done was negative, medication for sickle cell trait resolved all pain. The examiner also determined that hip pain also resolved. After service, on VA examination in September 2000 it was noted that the Veteran had right hand pain and left hand pain since her brain surgery. The examiner stated that there was no specific injury for bilateral hand pain and right hip pain. No diagnosis was rendered for right hip pain and x-rays were normal. The examiner opined that bilateral hand pain was secondary to meningioma. On VA examination in February 2001, the Veteran reported having bilateral shin pain ever since her craniotomy in March 2000 for resection of meningioma. VA x-rays in February 2001 of the legs were normal. The examiner opined that bilateral tibia and fibula were normal. On VA examination for knee and legs in January 2021, the examiner opined that the Veteran had bilateral shin pain due to fibromyalgia. The Veteran reported having bilateral leg pain since service. On VA hip examination in January 2021 the examiner opined that the Veteran did not have a current diagnosis and determined that the right hip pain was due to fibromyalgia. On VA hand examination in January 2021 the examiner determined that the Veteran had bilateral hand pain due to fibromyalgia. In a VA opinion in January 2021 the examiner opined that it is less likely than not that any currently diagnosed disability related to the Veteran's bilateral hand pain was incurred in or caused by active service as the Veteran did not have an orthopedic hand condition during active service. As for the right hip and shin condition the examiner opined that it is less likely than not that the Veteran has any currently diagnosed condition related to her claimed right hip condition and shin condition that was incurred or caused by service. The examiner noted that service treatment records show one notation of hip pain and shin pain in August 2000 for two weeks, however since service there is no documentation of chronic hip pain. As for the right hip, recent records show documentation of fibromyalgia as a possible etiology of chronic pain. As for shin pain the examiner acknowledged that more recent records show the Veteran has a diagnosis of fibromyalgia. The examiner further opined that the Veteran's bilateral hand pain was less likely than not proximately due to or a result of the Veteran's fall resulting from her service-connected craniotomy and seizure disorder as the records show no documentation of a bilateral hand condition related to falls from the Veteran's craniotomy and seizure disorder. The examiner noted that there is documentation of fibromyalgia that can provide a diagnosis for the Veteran's bilateral hand pain. As for the right hip condition, the examiner opined that it is less likely than not that any currently diagnosed condition related to the Veteran's claimed right hip pain is proximately due to or a result of the Veteran's falls resulting from the service-connected craniotomy and seizure disorder. The Veteran's service treatment records show the Veteran had one complaint of right hip pain in August 2000 without mention of fall. After service the Veteran has been noted to have chronic pain related to fibromyalgia and there is no documented evidence to support that the Veteran has hip pain secondary to falls from her service-connected condition. As for shin pain the examiner opined that it is less likely than not that shin pain is proximally due to or a result of the Veteran's falls resulting from service-connected craniotomy and seizure disorder. Service treatment records show the Veteran was seen once for anterior shin pain and sensitivity in August 2000. After service she has been found to have chronic pain and a diagnosis of fibromyalgia causing widespread body pain. There is no documentation of a fall in the medical records causing bilateral shin pain. The examiner opined that it is less likely than not that any currently diagnosed condition related to the Veteran's claimed hand pain was aggravated beyond its natural progression by the Veteran's falls resulting from service-connected craniotomy and seizure disorder, noting that the Veteran has no current documentation of an orthopedic condition of the hands. The examiner further opined that it is less likely than not that the Veteran's hip condition, to include a diagnosis of hip pain, and shin pain was aggravated beyond its natural progression by the Veteran's falls resulting from the service-connected craniotomy and seizure disorder. The examiner explained that VA treatment records show no documentation of a hip injury or shin injury secondary to a fall from the service-connected craniotomy and seizure disorder. The examiner noted that there is no diagnosed orthopedic condition of the shins. The examiner explained that in order to support aggravation by a fall documentation needs to be present to establish that there was a fall that caused injury to the shins, or a baseline injury. The examiner stated that the Veteran had right hip pain due to fibromyalgia which resulted in functional impairment. The examiner further stated that the Veteran had shin pain and bilateral hand pain from her fibromyalgia that caused symptoms of pain with standing, walking and tenderness to touch of her shins, and caused burning pain associated with stiffness in her hands making activities such as prolonged typing difficult. The Board finds the January 2021 VA opinion to be probative as it was based on medical principles and applied to the facts of the case. Nieves-Rodriquez v. Peake, 22 Vet. App. 295 (2008). The Board acknowledges that the September 2000 VA examiner opined that bilateral hand pain was secondary to meningioma and that the Veteran during service underwent a resection for a right frontoparietal meningioma. However, unlike the January 2021 VA examiner, the examiner in September 2000 provided a conclusory opinion without adequate rationale for the conclusion reached. A mere conclusion statement is insufficient to allow the Board to make an informed decision as to the weight to assign to the medical statement. Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007). The Veteran is competent to report symptoms pertaining to her disabilities. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, the etiology of bilateral hand pain, right hip condition, and shin pain falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). These disabilities are not the type of conditions that are readily amenable to mere lay diagnosis or probative comment regarding their etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating such disabilities. Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. As the lay evidence is not competent, the matter of whether it is credible is not reached. For the reasons discussed above the preponderance of the evidence is against the claims for service connection for a disability manifested by right hand pain, left hand pain, right hip condition, and shin pain, to include as secondary to a service-connected disability, and the benefit-of-the-doubt standard of proof does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Mac, 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.