Citation Nr: 21023613 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 11-25 966 DATE: April 21, 2021 ORDER Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a left hip disability is denied. Entitlement to service connection for a right hip disability is denied. Entitlement to service connection for muscle pain, to include as a manifestation of an undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C. § 1117 is denied. FINDINGS OF FACT 1. Although the Veteran suffered a fall during his period of ACDUTRA, no lumbar spine or hip disability was shown during service or for many years thereafter; there is no credible evidence of continuity of lumbar spine or hip symptomatology since his fall during the period of ACDUTRA; and there is no other competent evidence that there exists a medical relationship, or nexus, between any of the later diagnosed lumbar spine and hip disabilities and service. 2. The Veteran does not have a qualifying disability involving muscle pain due to service, including service in Southwest Asia. CONCLUSIONS OF LAW 1. The criteria for service connection for a lumbar spine disability are not met. 38 U.S.C. §§ 101(2), (24), 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.6(a), 3.303, 3.307, 3.309. 2. The criteria for service connection for a left hip disability are not met. 38 U.S.C. §§ 101(2), (24), 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.6(a), 3.303, 3.307, 3.309. 3. The criteria for service connection for a right hip disability are not met. 38 U.S.C. §§ 101(2), (24), 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.6(a), 3.303, 3.307, 3.309. 4. The criteria for service connection for muscle pain have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1990 to May 1991, which includes service in Southwest Asia. He also had a period of active duty for training (ACDUTRA) with the Marine Corps Reserve from October 1984 to March 1985. He received the Combat Action Ribbon. This appeal to the Board of Veterans’ Appeals (Board) arises from February 2010 (right hip) and August 2011 (remaining claims) rating decisions. In January 2015, the Veteran testified during a Board videoconference hearing before a Veterans Law Judge. A transcript of that hearing is of record. However, the Veterans Law Judge is no longer employed by the Board. As such, the Veteran was notified in a February 2021 letter that he was entitled to another hearing before the Board. The Veteran did not respond within 30 days that he wanted an additional hearing. As such, the Veteran was notified that the Board will assume that he does not want an additional hearing and proceed with adjudication of his appeal. In May 2015, the Board granted the petition to reopen the claim for service connection for right hip and remanded the underlying claim for service connection for a right hip disability, as well as the claims for service connection for a lumbar spine disability, a left hip disability, and muscle pain, to the agency of original jurisdiction (AOJ) for further development. In August 2017, the Board denied the claims for service connection for lumbar spine, right hip and left hip disabilities, and remanded the claim for service connection for muscle pain to the AOJ for further development. The Veteran appealed the Board’s denial of the claims for service connection for lumbar spine, right hip and left hip disabilities to the United States Court of Appeals for Veterans Claims (Court). In June 2018, the Court granted a Joint Motion for Partial Remand (Joint Motion) filed by representatives for both parties that same month, vacating the portion of the Board’s August 2017 decision that denied service connection for lumbar spine, right hip and left hip disabilities, and remanding these matters to the Board for further proceedings consistent with the Joint Motion. The Board subsequently remanded the claims for service connection for lumbar spine, right hip, left hip and muscle pain for additional development in January 2019 and again in June 2020. A December 2020 supplemental statement of the case was most recently issued, and the case is once again before the Board. SERVICE CONNECTION 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a left hip disability. 3. Entitlement to service connection for a right hip disability. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The term “active military, naval, or air service” includes: (1) active duty; (2) any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C. § 101(2), (24); 38 C.F.R. § 3.6(a). In other words, service connection is available for diseases or injuries incurred in or aggravated by ACDUTRA and injuries incurred in or aggravated by INACDUTRA (including an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Regulations also provide that 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 which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Finally, 38 U.S.C. § 1154(a) requires that VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically, “[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The Board first considers whether entitlement to service connection for a low back disability, left hip disability and right hip disability is warranted on a presumptive basis. With respect to presumptive service connection under § 3.309(a), in light of the lack of medical evidence reflecting a diagnosis of a low back disability, left hip disability or right hip disability within one year of the Veteran’s separation from active service, service connection on a presumptive basis for these disabilities is not available. 38 C.F.R. § 3.309. Next, where the evidence does not warrant presumptive service connection, the United States Court of Appeals for the Federal Circuit has determined that an appellant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). However, the evidence does not show a causal relationship between the Veteran’s low back disability, left hip disability or right hip disability and any incident of active service. The Veteran contends that his lumbar spine and bilateral hip disorders are related to a fall that he sustained during his period of ACDUTRA from October 1984 to March 1985. Specifically, he has reported that he fell from a rappelling tower during boot camp. In a June 2008 statement (VA Form 21-4138), he appears to claim that he has experienced a continuity of lumbar spine and hip symptomatology in the years since service. The Board points out that the Veteran’s service personnel records reflect that he participated in Operation Desert Shield and Operation Desert Storm in Southwest Asia from December 1990 to April 1991 and that he participated in combat, as evident by his receipt of the Combat Action Ribbon. Where a veteran engaged in combat, satisfactory lay evidence that an injury or disease was incurred in service will be accepted as sufficient proof of service connection where such evidence is consistent with the circumstances, conditions, or hardships of service. 38 U.S.C. § 1154(b). Although the Veteran served in combat, he does not contend, nor does the evidence indicate, that his lumbar spine or hip disorders were incurred in combat with the enemy. Rather, he contends that the disorders were incurred during his period of ACDUTRA while in boot camp. Hence, the provisions of 38 U.S.C. § 1154(b) are inapplicable in this case. In support of his claim, the Veteran submitted an October 2010 statement from a fellow service member, in which R.L.M. reported that he went to boot camp with the Veteran in October 1984. During that time, R.L.M. was hospitalized for injuries and before he was discharged, the Veteran was brought for treatment after he had fallen approximately 25 feet from a rappelling tower. R.L.M. was unaware of the outcome of the Veteran’s treatment because they were not allowed to talk with one another. Hence, there is competent lay evidence that the Veteran sustained a fall during his period of ACDUTRA from October 1984 to March 1985. Although there is no contemporaneous evidence of treatment for injuries sustained in a fall in his service records, there is no evidence to explicitly contradict his reports of a fall in service, and he has submitted a statement from a fellow service member which confirms that he fell during his initial period of training. Conceding the fact that he experienced a fall in service, the claims for service connection for a lumbar spine, left hip and right hip disabilities must nevertheless be denied, as explained below. The Board notes that service treatment records reflect that at his separation examination in February 1985, from his ACDUTRA period of service, a clinical evaluation of his spine and other musculoskeletal was normal. In a report of medical history completed at that time, the Veteran denied recurrent back pain and additionally denied arthritis, rheumatism, or bursitis. A January 1989 examination completed prior to his second period of service once again noted a normal clinical evaluation of his spine and other musculoskeletal systems. A report of medical history at that time additionally noted no recurrent back pain or arthritis, rheumatism, or bursitis. Although he reported he had swollen or painful joints, further notation in the report appears to reflect this is related to his knees. Here, there is no evidence of any complaints of or treatment for back or hip problems in the Veteran’s service treatment records, and his February 1985 separation examination was normal other than for a scar. There is no report of any separation examination pertaining to the Veteran’s period of service from December 1990 to May 1991 included in his service treatment records. The evidence otherwise indicates that the Veteran’s current lumbar spine and hip disorders did not manifest until years after service. The Veteran’s reported history of continued symptomatology since active service has also been considered but is not found to be accurate. In making this determination, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant’s uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). Post service treatment records first reflect complaints of back pain in April 2003. A back disability was not diagnosed at that time. In an August 2007 x-ray report, the Veteran reported low back and right hip pain. X-ray findings of mild spondylosis at L2-3 and L3-4 and suspected mild congenital spinal stenosis involving the lower lumbar spine was documented at that time. The right hip x-rays were normal. Treatment records show complaints of right hip pain in August 2007 and left hip problems in a February 2008 operative report. The Board acknowledges that there is lay evidence of earlier lumbar spine and hip symptoms following service in that, as explained above, the Veteran has alluded to a continuity of lumbar spine and hip symptomatology in the years since service. As explained below, however, the Board finds that any current reports of a continuity of lumbar spine or hip symptomatology in the years since service are not credible. The absence of any clinical evidence of lumbar spine or hip problems for almost two decades after the Veteran’s initial separation from active service in March 1985 and for over a decade after his separation from his second period of service in May 1991 is one factor that weighs against a finding that his lumbar spine or hip disorders were present during those periods of service or in the year or years immediately after those periods of service. The Veteran has provided information and statements which are inconsistent with his report of a continuity of symptomatology. For instance, he alluded to a continuity of lumbar spine and hip symptomatology in the years since service on his June 2008 VA Form 21-4138. However, his service treatment records include reports of medical history forms dated in February 1985 and January 1989 on which he reported that he was neither experiencing, nor had he ever experienced, any recurrent back pain or “arthritis, rheumatism, or bursitis.” He reported during a March 2009 private treatment visit that he experienced “constant low back pain that [was] intermittently sharp and intermittent pain in the legs since November of 2007.” He reported during an April 2009 private treatment visit that he had experienced “ongoing back and hip pain since November of 2007.” During the January 2015 hearing, the Veteran reported that after he fell in service “everything seemed to be better and as the years went by everything seemed to get worse...” (see page 7 of the hearing transcript). Lastly, he reported during the October 2016 VA spine and hip examinations that after he fell in service he experienced leg pain, that he did not experience any low back or hip pain after his fall, and that low back and bilateral hip pain began in 2007. Given the absence of any evidence of complaints of or treatment for back or hip problems in the Veteran’s service treatment records, the fact that his February 1985 separation examination was normal other than for a scar, the absence of any clinical evidence of back or hip problems for many years following service, and the information and statements provided by the Veteran that are inconsistent with his report of a continuity of symptomatology, the Board concludes that, as to current assertions of continuity of lumbar spine and hip symptoms, any such reports are deemed not credible. Thus, neither the clinical record nor the lay statements of record establish a continuity of symptomatology in this case. Furthermore, the Board notes that, with respect to the medical etiology opinions of record, the competent, probative opinions weigh against the claims. In a January 2012 letter, the Veteran’s treating physician reported that he “reviewed the Veteran’s service medical records concerning the injury in 1984 and his private physician’s records complaining of lower back pain radiating down his left leg.” He concluded that “[t]his may have contributed” to the development of the Veteran’s avascular necrosis related to his hips and that avascular necrosis “can be caused by trauma.” There was no further explanation or rationale provided for this speculative opinion. October 2016 VA examinations and opinions were provided. The Court, in the June 2018 Joint Motion found inadequacies in the October 2016 medical opinions. As such, the Board finds they are accorded low probative value. Additional opinions were obtained in September 2019 and November 2020. A September 2019 VA examiner provided negative opinions, but based her opinions on the fact that service treatment records did not document a fall in service. The Board notes that the Veteran’s fall has been conceded, so little probative value is accorded to the September 2019 VA opinions. These inadequacies were noted in the June 2020 BVA remand and the claims were again remanded for an additional VA medical opinion. In November 2020 VA medical opinions, the VA examiner noted that the claimed conditions were less likely than not incurred in or caused by the claimed in-service event, or illness. After reviewing all of the evidence, the examiner noted that the Veteran had a total hip arthroplasty status post avascular necrosis, bilateral. She noted that previous trauma, long term corticosteroid use, and alcohol abuse are the most common risk factors for development of osteonecrosis of the femoral head (ONFH) however, idiopathic or primary ONFH in which the patient has no known risk factors is not an infrequent finding. The examiner noted that the underlying pathophysiological mechanism is reduction in blood flow to the subchondral bone of the femoral head and there is resulting bone death and collapse of the articular surface. She noted that the Veteran’s chronological records indicate a history of alcohol abuse. The VA examiner stated that the Veteran has the condition bilaterally. She considered his reports of falling from a rappelling tower in basic training. She noted that while injury or trauma can be associated with development of avascular necrosis, it is unlikely that the Veteran’s service, with the condition affecting both hips found more than 10 years after separation from his last period of active service, and far longer than that from the incidence reported that occurred in basic training, without any evidence of traumatic fracture or labral tear of dislocation, is related to the condition of the hip. She noted that the Veteran is known to have a major risk factor, alcohol use, which could be contributory to avascular necrosis. She also considered that the Veteran had been treated for other conditions in service and there was no mention of hip pain in either the 1985 or 1989 physical examinations. She noted that although the 1985 exam indicates there is foot and leg trouble, that is consistent with his treatment for shin splints, tendonitis, and blisters. After reviewing evidence, she concluded that the claimed right hip disability and the claimed left hip disability are less likely than not incurred in or caused by the claimed in service injury or events. With respect to the Veteran’s lumbar spine, the VA examiner opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. After reviewing the evidence, the examiner noted that the Veteran has degenerative changes of the lumbar spine and congenital spinal stenosis. She noted the Veteran’s reports of falling from a rappelling tower in basic training, and his reports that he was seen at medical and had x-rays at the time of injury. The examiner considered that back pain is reported many years after the fall in basic training and there is mention of mild degenerative changes and mild congenital spinal stenosis, which are not indicative of traumatic injury. She stated that there is no mention of traumatic arthritis or old fractures on the imaging or the specialty care visits with neurology, rheumatology, or orthopedics. She noted that the Veteran was seen for 1985 and 1989 examinations and there is no mention of back pain on either of those examinations. She noted that the Veteran marked no to recurrent back pain. The examiner considered the Veteran’s history as reported, supporting statements, imaging, medical records in and post service, and the hearing/remand and noted there is no medical evidence to support that his back condition is caused by in service exposure, illness, events or injuries. She concluded that the claimed condition of the lumbar spine is less likely than not incurred in or caused by the claimed in service injury or events. The Board finds that January 2012 private examination opinion is of minimal, if any, probative value because it is ambiguous and speculative and is not accompanied by any specific explanation or rationale. See Hood v. Shinseki, 23 Vet. App. 295, 296 (2009); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). By contrast, the November 2020 VA opinions are based upon a complete review of his medical records and reported history, are accompanied by a specific rationale that is generally consistent with the evidence of record, and addresses whether a relationship exists between the Veteran’s claimed lumbar spine and bilateral hip disabilities and service. Hence, the November 2020 opinions are adequate and entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). There is no other medical evidence or opinion indicating that the Veteran’s current lumbar spine disability, left hip disability, or right hip disability is related to service, and neither the Veteran nor his attorney has identified or alluded to the existence of any such evidence or opinion. While the Veteran has expressed his belief that his claimed disabilities are related to his in-service fall during a period of ACDUTRA, such assertions do not provide persuasive support for the claims. While he is certainly competent to describe matters within his personal knowledge, as a layperson not shown to have appropriate medical training and expertise, he is not competent to render a probative opinion on a complex medical matter, such as whether a medical relationship exists between his current lumbar spine and hip disabilities and a fall during a period of ACDUTRA (when his current lumbar spine and hip disabilities did not manifest for years following service), as resolution of such questions involves internal processes extending beyond an immediately observable cause-and-effect relationship. As the question of nexus in this case may not be competently addressed by lay evidence, the lay statements of record do not constitute competent, probative evidence on this point. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). See also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Under these circumstances, the Board must conclude that the record does not support a finding that the Veteran’s currently diagnosed lumbar spine disability, or his left or right hip disabilities, had their onset during service or are otherwise medically related to service. For all the foregoing reasons, each service connection claim currently under consideration must be denied. In reaching the decision to deny each claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, the benefit-of-the-doubt doctrine is not applicable, and, hence, not helpful in this instance. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 4. Entitlement to service connection for muscle pain, to include as a manifestation of an undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C. § 1117. The Veteran contends that that he has a muscle pain condition related to service in the Persian Gulf War. The Board notes that the Veteran has separately claimed service connection for joint pain and swelling of the joints and fatigue due to undiagnosed illness. These symptoms are not before the Board at this time and are outside the scope of the instant claim. Rather, the discussion below is limited to his claim for “muscle pain.” The Veteran is a Persian Gulf Veteran within the definition of 38 C.F.R. § 3.317 as a result of his documented service in Southwest Asia. See 38 C.F.R. § 3.2(i). As a Persian Gulf Veteran, the Veteran may be entitled to compensation if he exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317 which have manifested to a compensable degree either in service or no later than December 31, 2021, and such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317. Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving the skin, muscle or joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, and gastrointestinal signs or symptoms. 38 C.F.R. § 3.317(a), (b). A qualifying chronic disability means a chronic disability resulting an undiagnosed illness; a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms (chronic fatigue syndrome, fibromyalgia, functional gastrointestinal disorders (excluding structural gastrointestinal diseases). 38 C.F.R. § 3.317(a)(2)(i). A medically unexplained chronic multisymptom illness is a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). The determination of whether the illness is medically unexplained is particular to the individual Veteran in each case. See Stewart v. Wilkie, 30 Vet. App. 383, 391 (2018). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period are considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). By definition, section 1117 only provides compensation for symptoms of a chronic disability that have not been attributed to a known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). The Veteran is specifically seeking service connection for muscle pain due to undiagnosed illness. The Veteran was initially afforded a VA Gulf War General Medical Examination in October 2016. The examiner noted no diagnosis of fibromyalgia, myopathy, or any other musculoskeletal disease with an undiagnosed illness or a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology or a diagnosable chronic multi-symptom illness with a partially explained etiology. Although widespread musculoskeletal pain and stiffness were noted, an examiner specifically found no fibromyalgia. The Board in an August 2017 remand found inadequacies in the examinations provided and little probative value is accorded to the October 2016 VA examination. In a September 2018 Fibromyalgia VA examination it was noted that the Veteran did not have fibromyalgia. A Gulf War examination was also completed at that time. The examiner noted the Veteran’s reports of low back pain radiating to the right leg with right leg muscle pain. She noted that an extensive review of the medical records reflects no condition of fibromyalgia, and no condition of undiagnosed muscle pain. The VA examiner noted the Veteran’s reports of low back pain radiating to the right leg with right leg muscle pain was diagnosed as right lumbar radiculopathy and that local medical records including neurology and rheumatology and VA records indicate no fibromyalgia and no undiagnosed muscle condition. The examiner noted that fibromyalgia was self-reported by the Veteran in August 2010, which was not supported by the medical evidence or the Veteran’s symptoms. She concluded that since there is no fibromyalgia and no undiagnosed muscle pain per the medical records, the other medical opinions are not required. A medical opinion summary completed at the time noted the fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. She noted that researchers believe the fibromyalgia amplifies painful sensations by affecting the way the brain processes pain signals. The examiner noted the Veteran’s reports of low back pain to the right leg with right leg muscle pain. The examiner considered that the medical records indicate diagnosis of low back degenerative joint disease with right lumbar radiculopathy, degenerative joint disease, and right carpal tunnel syndrome. The examiner stated that the Veteran has no documented undiagnosed muscle pain, undiagnosed muscle disorder, or fibromyalgia. The Board, in a January 2019 remand noted inadequacies in this September 2018 opinion; therefore, little probative value is accorded to the September 2018 opinion. A September 2019 VA muscle opinion was provided. The VA examiner noted that an extensive review of the medial records indicated no condition of fibromyalgia and no condition of undiagnosed muscle pain. She noted the Veteran’s reported low back pain radiating to the right leg with right leg muscle pain, which has been diagnosed as right lumbar radiculopathy. The examiner noted that medical records including neurology and rheumatology and VA records indicate no fibromyalgia, and no undiagnosed muscle condition. She noted that fibromyalgia was self-reported by the Veteran in August 2010, which was not supported by medical evidence or the Veteran’s symptoms. The examiner noted that his right leg muscle pain is caused by lumbar radiculopathy that is due to his diagnosed lumbar spine degenerative arthritis. The examiner noted that this condition is a disease with a clear and specific etiology and diagnosis and is less likely as not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. In a June 2020 remand, the Board noted inadequacies of the September 2019 opinions. As such, little probative value is accorded to these opinions. A November 2020 VA medical opinion was also obtained. The examiner considered the evidence of record. She noted that the Veteran’s reported history, supporting statements, imaging, medical records in and post service, and the hearing/remand had been reviewed and there is no medical evidence to support that this muscle condition is caused by in-service exposure, illness, events or injuries. The examiner noted that the Veteran’s thorough evaluations include orthopedics, neurology, chronic pain clinic, and rheumatology. She noted that rheumatology typically diagnoses muscle pain of unknown etiology, such as fibromyalgia, and does not support this diagnosis. She noted that the pain reported by the Veteran is associated with multiple joint osteoarthritis or degenerative changes. The examiner reviewed the 2019 VA opinions and noted that while the EMG performed in 2009, ten years prior to this opinion, stated no definite evidence of neuropathy or radiculopathy, it is common for people to have radicular pain and symptoms prior to radiculopathy occurring on EMG/NCS. She noted that the Veteran has evidence in the record of 2010 lumbar stenosis and degenerative changes, both of which contribute to inflammation and pain of the exiting nerve roots from the spine. The examiner noted that a May 2010 follow up indicates there was improvement of the right lower extremity symptoms with epidural steroid injection performed, which further supports that a condition of radicular pain from the lumbar spine exists. In conclusion, the VA examiner found that the Veteran’s muscle pains are symptoms subsumed under other joint diagnoses, and they do not qualify as a separate diagnosis or condition that is caused by exposures in Southwest Asia. The Board finds that the examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board finds the November 2020 VA opinion to be the most probative evidence on this question. The Veteran’s contentions indicate a disagreement with the VA examiner’s professional medical judgment, but he does not have the qualifications to rebut it as this is a matter beyond the competence of a layperson to evaluate a condition under § 3.317. As indicated, that section specifically requires objective indications of a qualifying disability. Even were that not the case, it is beyond the competence of a lay person to distinguish between the etiology of muscle complaints in closely related anatomical areas, such as in his case. Hence, the Board gives more weight to the objective medical evidence. To the extent that the Veteran reports muscle pain symptoms, the VA examiner has found that his symptoms of muscle pain are related to joint diagnoses. As the Veteran’s symptoms have been attributed to a known diagnosis, the Gulf War provisions noted above do not apply as well. In sum, the more credible and probative evidence shows that the Veteran does not have a separate disability manifested by muscle pain. Rather, his symptoms have all been attributed to known diagnoses. As noted above, service-connection for his lumbar spine, to which his muscle pain has been attributed, is denied. The Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C. § 5107. Caroline B. Fleming Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. M. Clark, 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.