Citation Nr: 21010041 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 10-30 923 DATE: February 23, 2021 ORDER Service connection for a lumbar spine disability is denied. Service connection for a cervical spine disability is denied. FINDINGS OF FACT 1. The Veteran’s lumbar spine disability did not have its onset in service, did not manifest to a compensable degree within one year of discharge, and is not otherwise causally related to service, to include as secondary to service-connected pes planus. 2. The Veteran’s cervical spine disability did not have its onset in service, did not manifest as arthritis within one year of discharge, and is not otherwise causally related to service, to include as secondary to service-connected pes planus. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.   2. The criteria for entitlement to service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1973 to November 1975 and from September 1976 to September 1979. The Veteran died in August 2016. The Appellant is his surviving spouse. This matter is before the Board of Veterans’ Appeals (the Board) on appeal from the July 2009 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. The rating decision confirmed and continued the October 2008 denial of service connection for spondylosis, lumbar spine (previously claimed as acute osteoarthritis and back condition and hereinafter referred to as lumbar spine disability) and denied service connection for cervical spondylosis (claimed as neck problems and hereinafter referred to as cervical spine disability). The Veteran’s Notice of Disagreement (NOD) was received in August 2009. The Statement of the Case was issued in July 2010, and the Veteran’s VA Form 9, substantive appeal to the Board was received in July 2010. Most recently, in an October 2020 decision, the Board remanded the claims for further development and adjudication. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1131, 1137; 38 C.F.R. § 3.303.  Generally, to establish service connection, there must be lay or medical evidence of (1) a current disability, (2) incurrence or aggravation of a disease or injury in service, and (3) a nexus between the in-service injury or disease and the current disability. Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).  Service connection for certain chronic diseases, including arthritis, may also be established on a presumptive basis by showing that such a disease was manifested to a degree of 10 percent or more within one year from the date of separation from service.  38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a).  In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service.  38 C.F.R. § 3.307(a).  To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or, if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service.  The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998).  Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).  The credibility and weight of all the evidence, including the medical evidence, should be assessed to determine its probative value, and the evidence found to be persuasive or unpersuasive should be accounted for, and reasons should be provided for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value.  It is the Board’s responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Then, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102.  1. Entitlement to service connection for a lumbar spine disability. 2. Entitlement to service connection for a cervical spine disability. The Appellant seeks service connection for a lumbar and cervical spine disability. Because the Appellant claims that these disabilities have the same etiology, they are discussed together. In August 1974, the Veteran’s service treatment records (STRs) contain treatment for lower back pain which lasted for one day. It was noted that the prior day the Veteran fell off an ammunition truck. There was no other pain except for his lower back. It was noted that there was slight diffuse tenderness and that range of motion was normal. There was no spasm on motion noted. The Veteran was diagnosed with a low back strain. He was recommended to treat his back with heat and was ordered no lifting for one day. The next day the Veteran was seen for follow up. He complained of pain and har full range of motion with pain on flexion. He was noted to have good distal muscle strength. He was diagnosed with a low back strain and ordered to not do any heavy lifting for two days. A January 1975 note in the Veteran’s STRs indicates that he fell on his back and complained of mild pain in the upper lumbar and lower thoracic region. He was noted to have a mild contusion. There was no follow up care. A July 1975 separation examination did not reveal any problems. The Veteran’s spine was noted to be normal upon examination. A July 1976 in-service examination did not reveal any problems. The Veteran’s spine was noted to be normal upon examination. A July 1976 Report of Medical history indicates that the Veteran did not have arthritis, bone joint or other deformity, or back pain. The Report contains a statement completed by the Veteran indicating that he is in good health. The Veteran’s STRs contain what appears to be a copy of a September 1976 entrance examination for the Veteran’s second tour of active duty. The report is mostly not legible. However, the last page indicates that the Veteran qualified for active duty. A February 1977 note within the Veteran’s STRs indicates that the Veteran injured his back while at the beach and complained of low back pain. He was noted to have a mild contusion. The Veteran’s STRs contain several treatment notes regarding his neck in April 1977. An April 4, 1977 note indicates that the Veteran injured the left side of his neck. He was noted ot have severe pain of the middle posterior of his neck and difficulty turning his head. X-rays did not reveal evidence of a fracture. The Veteran was diagnosed with a muscle strain. April 11, 1977 X-rays of the cervical spine were negative. An April 11, 1977 treatment indicates that the Veteran fell off a ladder while on leave. He was noted to have decreased ROM in all aspects and spasms. He was diagnosed with a myofascial strain secondary to fall. The Veteran’s discharge examination for the second tour of duty took place in July 1979. The report is largely not legible, but the last page indicates that the Veteran qualified for discharge. A September 1979 Statement of Medical Condition indicates that the Veteran’s discharge examination took place in July 1979 and that there have been no changes in the Veteran’s condition. The Statement was signed by the Veteran. Because the July 1979 discharge examination is not legible, the STRs are incomplete in this case. When STRs are incomplete, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. See O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Russo v. Brown, 9 Vet. App. 46 (1996). However, missing records do not create a presumption either in favor of or against a claim. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005). A May 1989 VA examination report indicates that the Veteran complained of pain in his lower back. He reported that his pain began about three years prior and was in the middle of the low back without radiation. He also reported that he has never seen a doctor for it and that approximately two to three times per week he will have some mild aching in the middle of the low back radiating in the hips and posterior thighs brought on by such activities as basketball and prolonged standing. The Veteran denied numbness or weakness in his legs. The VA examination report indicates that examination of the lumbar spine showed no deformity or tenderness, with full flexion and extension, and lateral bending to the right and left. The Veteran underwent lumbar spine x-rays and the findings were noted to be within normal limits. The Veteran was diagnosed with intermittent lumbar strain, with no evidence of radiculopathy. A November 1995 VA x-ray report of the cervical spine indicates that the Veteran had normal alignment and vertebral body heights. He also had small anterior and posterior spurs seen throughout the cervical spine. His prevertebral soft tissues were normal. The impressions noted mild degenerative changes with no acute abnormality. A February 2003 VA x-ray report of the lumbar spine indicates that the Veteran has chronic low back pain which radiates down to both legs. He was noted to have facet sclerosis at L5-S1. His vertical vertebral body heights and intervertebral disc spaces were noted to be normally maintained. He was noted to have very mild degenerative changes with an otherwise negative report. A September 2004 VA hospital admission note indicates that the Veteran was admitted for substance abuse. Under past medical history, it was noted that the Veteran had a history of low back pain and bilateral foot pain since 1974 when he had frost bite to his feel and artillery fell on his feet. It was noted that his back pain is intermittent. A November 2005 VA emergency department note indicates that the Veteran was seen due to psychiatric symptoms. He underwent a general examination and it was noted that his neck had no masses, crepitus, or tracheal deviation. His neck was noted to be supple with no tenderness, mass or thyroid enlargement. His past medical history did not include any neck or back problems. A January 2008 VA treatment note indicates that the Veteran was seen with worsening low back pain lasting for four weeks. It was noted he was seen with similar complaints one week ago and was given pain medication which caused no improvement. The Veteran reported muscle spasm. Under musculoskeletal, it was noted that the Veteran had normal range of motion and strength with no joint enlargement or tenderness in his upper extremities. The Veteran was ordered to undergo imaging studies of the cervical and lumbar spine. A January 2008 VA CT of the lumbar spine indicated minimal osteoarthritis of the facets at L5-S1 with an otherwise normal study within normal limits for age. A January 2008 VA x-rays of the lumbosacral spine indicated mild degenerative changes at the lower lumbar fact joints. There was no other abnormality seen. The report also indicates that these changes are stable compared to the February 2003 examination. An August 2008 VA emergency treatment note indicates that the Veteran was a passenger in the back seat of a vehicle when the car he was travelling in was hit by an 18-wheeler. The Veteran reported the accident happening the day before, and waking up with his neck, back, and left side hurting. August 2008 VA cervical spine x-ray indicated degenerative changes and mild prevertebral soft tissue edema. The Veteran was diagnosed with a muscle strain/sprain secondary to a motor vehicle accident. A September 2008 VA emergency treatment note indicates that the Veteran was seen for neck and back pain which he believes were aggravated by a recent motor vehicle accident. The note indicated that the Veteran was x-rayed in August 2008. The Veteran reported still taking medication and his back bothering him. He felt better after being up and around. He reported feeling stiff after inactivity. The Veteran was not noted to have any spinal deformities. He was able to walk on his heels and toes. He was noted to have chronic low back pain and prescribed different medication for treatment. In June 2009, the Veteran underwent a VA examination for his neck and back. The Veteran reported experiencing neck and back pain since 1974. He stated that he fell down a flight of stairs and has experienced significant neck and back pain since. The Veteran reported that his pain radiated to his left arm and left leg, with numbness and tingling in all of his fingers, hands, ankles, and feet. The Veteran also reported having a hairline fracture of C3 in 1970s as a result of the fall down the stairs. The Veteran was noted to use a cane, but not a neck brace. He reported flare ups of pain getting significantly worse with increased movement, walking, and sitting up from a chair. The Veteran reported the flare ups to last several hours if not for the rest of the day. He denied past surgery or injections. He reported being in physical therapy for several years and treating his pain with medications which have moderate effect. The Veteran reported being put on bed rest because of his neck and back. The Veteran was noted to wear a knee brace on both of his knees and having a slow but steady gait. Examination revealed mild tenderness to palpation throughout the Veteran’s cervical, thoracic, and lumbar spine. There was no muscle atrophy, but the Veteran had decreased sensation to his upper extremities. The VA examiner referenced August 2008 imaging studies which revealed degenerative changes from C3-C7 with large osteophytes noted at those levels. August 2008 lumbar imaging studies revealed degenerative changes at the L4-L5 facet along with L5-S1 facet. The Veteran was diagnosed with cervical spondylosis and lumbar spondylosis. The VA examiner concluded that the Veteran’s neck and low back pain are less likely as not the result of his fall down a flight of stairs in 1974. The VA examiner indicated that degenerative changes in the neck and spine are genetic in nature and that the Veteran’s appeal to related to osteoarthritis. Pursuant to the July 2019 Board remand, the June 2009 VA medical opinion is inadequate as pertinent service records have been added to the file and as the June 2009 VA examiner only addressed the 1974 injury. An August 2012 VA podiatry evaluation indicates that the Veteran sustained a left fibular fracture in early January 2011. The Veteran was noted to have pain radiating to his leg and causing him to walk with a limp. A September 2012 VA nursing admission note indicates that the Veteran was admitted for psychiatry. He was noted to be obese, with a gait problem and in a wheelchair due to chronic back pain. In June 2013, the Veteran underwent a VA examination for his back. The Veteran reported sharp pain in the lower back radiating into lower extremities to the knees. The Veteran reported injuring his back in a motor vehicle crash in 2008. He reported flare ups consisting of increased pain. The VA examiner concluded that the Veterans disability is less likely than not proximately due to or the result of the Veteran’s service-connected disabilities. The VA examiner indicated that the Veteran sustained a back injury in 2008 and that it is more likely that his current back disability of mild lumbar spondylosis is related to that accident than his current pes planus. Pursuant to the November 2014 Board remand, the June 2013 examination report was incomplete as it did not address whether the Veteran’s cervical or lumbar disabilities have been aggravated by his service-connected pes planus. An October 2013 VA treatment note indicates that the Veteran was seen in the emergency room. He was noted to have normal gait. A November 2013 VA treatment note indicates that the Veteran uses a manual chair to mobilize, and that his gait is slow and cautious. The Veteran’s back was noted to have lordosis. A March 2014 VA treatment note indicates that the Veteran had difficulty walking and had morbid obesity. In December 2014, the VA produced a clarification opinion regarding the issue of aggravation. The VA examiner indicated that the Veteran’s back, neck, and flat feet are very common medical conditions. The VA examiner further indicated that there was no evidence for altered gait or change in alignment due to pes planus. The VA examiner concluded that the Veteran’s neck and back disabilities are not related to pes planus and that it is less likely than not that the neck and back disabilities are due to or aggravated by pes planus. In January 2015, the VA produced an addendum medical opinion. With respect to the Veteran’s cervical spine disability, the VA examiner indicated that the Veteran’s condition clearly and unmistakably existed prior to service, and was not aggravated beyond its natural progression by an in-service event, injury or illness. The VA examiner indicated that a review of the STRs, previous VA examinations, and available records does not show evidence of abnormal posture, stance, gait, or any evidence of abnormal pressures or forces placed on the Veteran’s cervical spine as a result of his foot condition. The VA examiner also indicated that because of that, there is no mechanism by which the Veteran’s foot condition would aggravate the Veteran’s cervical spine condition. With respect to the lumbar spine disability, the VA examiner indicated that it clearly and unmistakably existed prior to service, and was not aggravated beyond its natural progression by an in-service event, injury, or illness. The VA examiner indicated that a review of the STRs, previous VA examinations, and all available records does not show evidence of abnormal posture, stance, gait, or any other evidence of abnormal pressures or forces placed on the lumbar spine due to the Veteran’s foot condition. The VA examiner then concluded that because of that, there is no mechanism by which the Veteran’s foot condition would aggravate the Veteran’s lumbar spine condition. Pursuant to the August 2016 Board remand, the January 2015 VA medical opinion was inadequate as it erroneously mischaracterized the Veteran’s disabilities as pre-existing. In a May 2016 informal hearing presentation (IHP), the Veteran, through his representative, contended that his lumbar and cervical spine disabilities are related to and/or aggravated by his service-connected bilateral pes planus. The IHP also indicates that while the Veteran did use a motorized scooter, there is a documented history of him having antalgic gait. In October 2018, the VA produced an addendum medical opinion. The VA examiner noted that the Veteran passed away in August 2016. The VA examiner indicated that they reviewed the VA examinations after year 2000, and that pes planus and diabetic neuropathy can both result in abnormal gait. The VA examiner then stated that without an examination, they would have to resort to speculation which is the equal, major, or minor cause. Pursuant to the July 2019 Board remand, the October 2018 VA addendum opinion is inadequate as it is speculative and does not address the opinions that were requested. In December 2019, the VA produced an additional addendum opinion. The VA examiner indicated that the Veteran had low back pain on August 10, 1974 after falling off an ammo truck and that his range of motion was normal with no spasm. The VA examiner indicated that the Veteran was diagnosed with a back strain. The VA examiner then indicated that the Veteran was seen the next day with a low back strain and was told to not do heavy lifting. The VA examiner further noted that the Veteran’s July 1975 discharge examination along with 1976 entrance examination did not indicate a chronic back condition. The VA examiner concluded that as a result of this the Veteran’s back condition is less likely than not related to this period of time. The VA examiner then indicated that the Veteran was seen for neck pain in April 1977, at which point he was diagnosed with a cervical strain and treated with a soft collar. The VA examiner noted that the Veteran was seen on April 11th and 12th with a diagnosis of resolving cervical strain and that his x-rays were negative. The VA examiner concluded that a chronic neck or back condition could not be established for this period of service. The VA examiner then indicated that they could not find a good copy of the Veteran’s 1979 discharge examination, and that all further opinions with respect to the Veteran’s disabilities could not be provided without resorting to speculation. The VA examiner noted that unless additional records are available, they cannot conclude without mere speculation whether the Veteran’s cervical spine disability had its onset in service or manifested as arthritis within one year of discharge or was otherwise causally related to service. The VA examiner concluded that they could not find evidence in support of per planus causing or aggravating the Veteran’s back or neck condition. Pursuant to the October 2020 Board remand, the December 2019 VA medical opinion is inadequate with respect to the theory of secondary service connection related to pes planus. In October 2020, the VA produced an addendum medical opinion. The VA examiner indicated that cervical spine spondylosis and lumbar spine spondylosis are not medically related and that both disabilities are entirely separate entities form the Veteran’s service-connected pes planus. The VA examiner then went on to state that the medical literature does not support a relationship between the two disabilities and pes planus. The VA examiner cited orthopedic literature and indicated that there is no clear evidence to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5 cm so that the individual’s gait pattern has been altered to the extent that clinically there is an obvious Trendelenburg gait. The VA examiner indicated that it is not unusual for two joints to share properties int eh same person, but one joint disease does not “spread” to another or cause damage to it. The VA examiner then indicated that cervical spine spondylosis is due to something intrinsic to the cervical spine and not the low back. The VA examiner also indicated that lumbar spondylosis is due to something intrinsic to the low back and not the cervical spine. The VA examiner concluded that they could not determine a baseline level of severity for either disability because the medical evidence is not sufficient to support a determination of a baseline level of severity. The VA examiner then indicated that a 2010 rating decision demonstrates forward flexion of 35 degrees and combined range of motion of 285 degrees, which falls within the projected natural history of the condition and does not represent aggravation beyond the natural progression. Then, the VA examiner indicated that the June 2013 VA examination report demonstrates a normal range of motion and normal lower extremity strength, which falls within the projected natural history of the condition and does not represent aggravation beyond the natural progression. The VA examiner concluded that the Veteran’s cervical and low back disabilities were not aggravated beyond their natural progression by a different medical condition because the same range of motion readings did not represent aggravation. Based on the above, the preponderance of the evidence is against the finding that the Veteran’s cervical and lumbar spine disabilities had their onset in service, manifested as arthritis to a compensable degree within one year of discharge, or were otherwise causally related to service, to include as secondary to the Veteran’s service-connected pes planus. As such, service connection is not warranted. The Veteran’s cervical lumbar and cervical spine disabilities did not have their onset in service and did not manifest as arthritis within one year of discharge. The most probative evidence of record indicates that the Veteran’s lumbar spine disability manifested as arthritis in February 2003 with earliest recorded reports of pain in 1986. See May 1989 VA examination report and February 2003 VA lumbar x-ray report. The Veteran’s cervical spine disability manifested as arthritis in November 1995 with earliest recorded reports of pain onset at the same time. See November 1995 VA x-ray report. This is well outside the one-year post-discharge window. While the Veteran reported having low back and neck pain since service, the objective x-ray evidence ruled out arthritis until the November 1995 VA cervical x-rays and the February 2003 VA lumbar x-rays. Moreover, the record reveals inconsistencies with respect to the Veteran’s reported history of back and neck pain. For instance, during the May 1989 VA examination the Veteran did not report any neck pain and reported having intermittent low back pain for approximately three years. The September 2004 VA hospital admission note indicates that the Veteran reported history of low back pain and foot pain only, dating back to 1974. There was no mention of neck pain. During the June 2009 VA examination, the Veteran reported back and neck pain since 1974. Also during the June 2009 VA examination, the Veteran reported injuring his back in 1974 by falling down the stairs. To the contrary, the Veteran’s STRs indicate that the 1974 injury was sustained when the Veteran fell from an ammunition truck. These statements are not afforded significant probative value because they are inconsistent and have been contradicted by the medical evidence of record. Namely, the Veteran’s July 1976 in-service Report of Medical History and his September 1976 discharge examination, indicating that the Veteran did not have a history of back or neck pain dating back to 1974. Of note, the Veteran’s STRs contain an August 1974, a January 1975, and a February 1977 treatment for back injuries, as well as an April 1977 treatment for a neck injury. The August 1974 and January 1975 injuries resulted in a diagnosis of a back strain and a mild contusion respectively and resolved prior to the September 1976 discharge. See September 1976 discharge examination. The February 1977 back injury was also noted to be a mild contusion while the April 1977 neck injury was diagnosed as a myofascial strain. The probative evidence of record indicates that these injuries also resolved after conservative treatment. Namely, the February 1977 back contusion did not involve any follow up care. The treatment for the April 1977 injury involved a negative cervical spine x-ray and no follow up after April 1977. There were no other in-service injuries to the Veteran’s neck or back, and the Appellant has not contended otherwise. While the September 1979 discharge report is not legible, the remainder of the Veteran’s STRs are complete, and do not indicate any other treatment or injuries to his back or neck. The December 2019 VA addendum opinion corroborates these findings. After a thorough review of the Veteran’s records, the VA examiner indicated that the April 1977 injury involved a resolving cervical strain, and that they could not establish a chronic back or neck condition to this period of service. The December 2019 VA addendum opinion with respect to direct service connection is afforded substantial probative value as the Veteran’s records were thoroughly reviewed and a full rationale was provided for the conclusions reached. Thus, the probative evidence of record supports a finding that the Veteran’s lumbar and cervical spine disabilities did not have their onset in service and did not manifest as arthritis within one year of discharge. Absence of the September 1979 discharge examination cannot cure the deficiencies in the Appellant’s claim as the existing records illustrate that the in-service injuries were conservatively treated and resolved without follow up care. See O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Russo v. Brown, 9 Vet. App. 46 (1996) With respect to nexus, the evidence of record is against the finding that the Veteran’s back or neck disabilities were related to service, to include the aforementioned in-service injuries. In this regard, the Veteran underwent 3 separate VA examinations, in addition to which the VA produced 5 separate addendum opinions. See May 1989 VA examination report, June 2009 VA examination report, June 2013 VA examination report, December 2014 VA addendum opinion, January 2015 VA addendum opinion, October 2018 VA addendum opinion, December 2019 VA addendum opinion, and October 2020 VA addendum opinion. In spite of this lengthy development, no VA examiner was able to link the Veteran’s disabilities to his service. While several of these opinions have been deemed incomplete or inadequate, the totality of the evidence supports the conclusions reached therein. Specifically, the June 2009 VA examiner concluded that it is less likely than not that the Veteran’s disabilities are due to the 1974 in-service fall down the stairs. This opinion is incomplete as it only addresses that injury. Of note, the June 2009 opinion was also considered inadequate because STRs were added to the record after the opinion. However, those STRs were for the Veteran’s second tour of duty, which did not cover the dates for the 1974 injury, and the separation examination from the first tour of duty did not indicate any back problems. Thus, the June 2009 VA medical opinion is afforded probative value to the extent that it addresses the nexus to the 1974 in-service injury. Next, the June 2013 VA medical opinion indicates that the Veteran’s lumbar spine disability is less likely than not proximately due to, or the result of his service-connected disabilities. The June 2013 VA examiner also indicated that the Veteran’s lumbar spine disability likely related to the 2008 motor vehicle crash. The opinion was noted to be incomplete because the issue of aggravation was not discussed. However, the June 2013 VA medical opinion is afforded probative value to the extent that it concludes that the Veteran’s lumbar spine disability was not a result of his service-connected disabilities. Moreover, the October 2020 VA addendum opinion adequately addressed the issue of aggravation. Finally, the December 2019 VA addendum opinion indicates that the Veteran’s disabilities were not related to any of the already-mentioned in-service injuries, or any other injuries for that timeframe. The December 2019 VA examiner was likewise unable to link the Veteran’s disabilities to his service. Thus, based on the totality of the VA medical opinions as well as the medical evidence, the Veteran’s lumbar spine and cervical spine disabilities are less likely than not related to his service, to include the claimed in-service injuries. The VA medical opinions indicate, and evidence corroborates, that the disabilities had their onset many years after service, were likely result of the natural aging process, and did not have a connection to the in-service injuries. While the Appellant sincerely believes that the Veteran’s back and neck disabilities relate to his service, the Appellant is not competent provide a medical nexus opinion as to a relationship between the Veteran’s disability and service; or, any other disease or injury in service.  This requires medical expertise and falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011).  In this regard, any actual diagnosis of a back disability, and causation between service and disability, requires objective testing and medical expertise to diagnose.  See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).  To the extent that the Appellant believes that the Veteran’s lumbar and cervical spine disabilities were caused by service and his in-service injuries, as a lay person, she is not shown to possess any specialized training in the medical field. The Appellant is not deemed competent to know the cause of lumbar spine disability, as this is an internal physiological process that requires medical expertise. Even if the Veteran’s inconsistent reports of back and neck pain were taken into consideration,  the preponderance of the most probative and competent evidence of record is against finding that the back and neck pain associated with the disabilities at issue, were the cause of the same cause of the back pain and neck pain that the Veteran experienced in service. Accordingly, the Appellant’s opinion as to the nexus in this case is not competent evidence. Id.   With respect to the Appellant’s claim that the Veteran’s lumbar and cervical spine disabilities are secondary to the service-connected pes planus, the contention is that the Veteran’s pes planus caused antalgic gait, which in turn caused or aggravated his lumbar and cervical spine disabilities. However, the October 2020 VA addendum medical opinion indicates that the Veteran’s lumbar and cervical spine disabilities were not related to or aggravated by his service-connected pes planus. The VA examiner indicated that pes planus and lumbar and cervical spine disabilities are not medically related. The VA examiner also concluded that the Veteran’s disabilities fell within the projected natural history of the disabilities, and therefore were not aggravated beyond their natural progression. The October 2020 VA addendum medical opinion contains a thorough review of the medical history with respect to the two disabilities, including recorded ranges of motion, in support of their contention the Veteran’s disabilities were not aggravated by pes planus or any other disability. Moreover, the October 2020 VA addendum medical opinion addresses the Appellant’s contention that the Veteran’s abnormal gait caused or aggravated his lumbar and cervical spine disabilities and indicates that there was no causation or aggravation. The VA examiner cited appropriate orthopedic literature in support for their conclusions, listing actual medical conditions that would have caused such aggravation (such as shortening of a limb or Trendelenburg gait), and provided full rationale for the conclusions reached. The conclusions within the October 2020 VA addendum medical opinion are corroborated by the Veteran’s VA treatment records. For example, the records indicate that the Veteran’s gait was abnormal, but did not amount to Trendelenburg gait or shortening of a limb. Additionally, the Veteran’s VA treatment records suggest that his antalgic gait was related to conditions other than pes planus, such as diabetic neuropathy. Finally, the January 2008 VA imaging studies indicate that the Veteran’s lumbar osteoarthritis was within normal limits of age and the changes were stable compared to the February 2003 imaging, suggesting that the lumbar disability was not aggravated beyond its natural progression. Given that the October 2020 addendum medical opinion cites appropriate medical literature, is corroborated by the record, and includes a full rationale for the conclusions reached, it is afforded probative value. As the record indicates that the Veteran’s lumbar and cervical spine disabilities were not caused by or aggravated by his service-connected pes planus, the preponderance of the evidence is against the claim for service connection on a secondary basis. In sum, the preponderance of the evidence is against a finding that the Veteran’s lumbar and cervical spine disabilities had their onset in service, manifested as arthritis within one year of discharge, or were otherwise related to service, to include as secondary to the Veteran’s service-connected pes planus.  Accordingly, the benefit-of-the-doubt rule enumerated in 38 U.S.C. § 5107(b) is not for application, and service connection is not warranted.   Z. SAHRAIE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kuksova, Kseniya 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.