Citation Nr: 21023689 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 18-32 749 DATE: April 21, 2021 ORDER Entitlement to service connection of left wrist radiocarpal disease is denied. Entitlement to service connection of right wrist radiocarpal disease is denied. Entitlement to service connection of right wrist tendonitis is denied. Entitlement to service connection of hypertension is denied. Entitlement to service connection of gastroesophageal reflux disease (GERD) is denied. Entitlement to service connection of duodenitis is denied. Entitlement to service connection of arthritis of the right foot is denied. Entitlement to service connection of degenerative arthritis of the thoracolumbar spine is denied. Entitlement to service connection of left lower extremity peripheral neuropathy is denied. REMANDED Entitlement to service connection of a bilateral hip condition is remanded. FINDINGS OF FACT 1. The Veteran’s left wrist radiocarpal disease did not manifest during or within one year of separation from active service; it is less likely than not related to any incident of active service; it is less likely than not caused or aggravated by his right wrist carpal tunnel syndrome. 2. The Veteran’s right wrist radiocarpal disease did not manifest during or within one year of separation from active service; it is less likely than not related to any incident of active service; it is less likely than not caused or aggravated by his right wrist carpal tunnel syndrome. 3. The Veteran’s right wrist tendonitis is less likely than not related to any incident of active service; it is less likely than not caused or aggravated by his right wrist carpal tunnel syndrome. 4. The Veteran’s hypertension did not manifest during or within one year of separation from active service; it is not caused or aggravated by his service-connected PTSD. 5. The Veteran’s GERD is less likely than not related to any incident of active service; it has not been caused or aggravated by his ulcer. 6. The Veteran does not have a diagnosis of duodenitis. 7. The Veteran does not have right foot arthritis or any other diagnosis in the right foot beyond his already service-connected right foot fallen arch. 8. The Veteran’s arthritis and degenerative disc disease of the thoracolumbar spine did not have onset during or within one year of separation from active service; it is not otherwise related to any incident of active service, to include his 2003 complaints of muscle spasms in the low back. 9. The Veteran’s left lower extremity peripheral neuropathy is a neurological complication of his non-service-connected arthritis and degenerative disc disease of the thoracolumbar spine. CONCLUSIONS OF LAW 1. The criteria for service connection for left wrist radiocarpal disease due to service or right wrist carpal tunnel syndrome are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.307, 3.309, 3.310. 2. The criteria for service connection for right wrist radiocarpal disease due to service or right wrist carpal tunnel syndrome are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.307, 3.309, 3.310. 3. The criteria for service connection for right wrist tendonitis due to service or right wrist carpal tunnel syndrome are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.307, 3.309, 3.310. 4. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for service connection for GERD are not met. 8 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.307, 3.309, 3.310. 6. The criteria for service connection for duodenitis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for right foot arthritis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for service connection for arthritis and degenerative disc disease of the thoracolumbar spine are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 9. The criteria for service connection for left lower extremity peripheral neuropathy due to service or a thoracolumbar spine disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1985 to November 1992, and from September 2002 to August 2003. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from April 2016, August 2016, May 2017, and July 2017 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran testified before the undersigned Veterans Law Judge. A transcript of that hearing is of record. As a matter of procedural background, this appeal previously came before the Board in July 2019, at which time the Board declined to reopen claims related to the left and right wrists, as well as bilateral knee disabilities, based on a lack of new and material evidence. The Board also remanded the issues pertaining to the bilateral hips, hypertension, GERD and duodenitis, right foot arthritis, the thoracolumbar spine, and left lower extremity peripheral neuropathy, for additional development. During the pendency of that development, the Veteran appealed the Board’s decision to not reopen the wrist and knee claims to the Unites States Court of Appeals for Veterans Claims (Court), and in April 2020, the Court granted a Joint Motion for Partial Remand (JMPR), in which the parties agreed that those issues should be returned to the Board for further appellate review. In October 2020, the Board issued a decision reopening the bilateral wrist and knee claims, and remanding them for further development. It is noted that due to that development, the right and left knee claims were subsequently granted in full by the RO, and they are no longer before the Board as part of this appeal. The wrist claims are now returned to the Board, as well as the other service connection issues which were previously remanded by the Board in July 2019. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, certain chronic diseases, including arthritis and hypertension, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Regardless of whether a condition is listed as chronic for presumptive purposes, a continuity of symptoms from the time of service is a factor to consider when assessing a service-connection claim. A disability may also be found service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. 1. Entitlement to service connection of left wrist radiocarpal disease 2. Entitlement to service connection of right wrist radiocarpal disease 3. Entitlement to service connection of right wrist tendonitis The Veteran seeks service connection of right wrist tendonitis, and bilateral wrist radiocarpal disease. The Board finds that the claim should be denied. As an initial matter, the Board recognizes current diagnoses of right and left radiocarpal joint disease, as well as an earlier diagnosis of right wrist tendonitis. A review of his service treatment records do not confirm any specific right or left wrist injury or any incident or illness to which the presently diagnosed disabilities could be etiologically linked, although in August 2003, his separation examination noted popping in the bilateral wrists. For his part, the Veteran asserts that his wrist issues are related to years of physical training to include push-ups. He asserted that he developed wrist issues during active service, and has had issues with his wrist from that time. In February 2016, the Veteran was afforded a VA examination which declined to diagnose any wrist disabilities, despite earlier evidence of a diagnosis of right wrist tendonitis. Despite the RO de facto reopening these claims, the Board concluded that no new and material evidence had been submitted to adjudicate earlier denials of these disabilities, as the evidence failed to show any new evidence of a nexus to service. Following the JMPR in 2019, the Board found adequate evidence to reopen the appeal, and remanded it for further development to include obtaining a new examination and opinion. He was afforded a new VA examination in January 2021, per the Board’s most recent remand. The examiner confirmed the bilateral radiocarpal disorder, but did not find any present evidence of tendonitis. The Veteran reported to the examiner that he had developed wrist issues during active service, with audible pops with rotational movements. He stated that the popping sensation causes pain and occasional locking up; however, when he demonstrated this movement to the examiner, he had full reduction of both wrists. He stated that he occasionally wore a wrist brace in the evening. He denied flare-ups. He stated that sometimes his wrists “lock up.” Range of motion was completely normal on all planes of movement. He was able to perform repetitive use testing with no further loss. Muscle strength testing was all complete and normal. He did not have ankylosis or immobilization of either wrist joint. The examiner conducted a thorough review of the Veteran’s medical history, and included that in the examination report. The examiner then stated that the popping symptoms noted in the wrists in 2003 were unlikely to be from degenerative changes of the wrists as imaging of the left and right wrists in November 0211 were normal, and degenerative changes were only first noted in February 2017. This the diagnosed radiocarpal degenerative joint arthritis in 2017 was less likely than not incurred in or caused by the in-service popping noted in August 2003. To the extent that the Veteran has been granted service connection of right upper extremity carpal tunnel syndrome, the examiner stated that the presently claimed disabilities were less likely than not caused by or aggravated beyond their natural progression by the carpal tunnel syndrome. In support of this the examiner noted that there is absolutely no pathophysiological correlation between right upper extremity carpal tunnel and the development of radiocarpal joint degenerative arthritis. Carpal tunnel syndrome is a neuropathy resulting from compression of the medial nerve in the flexor retinaculum and does not cause degenerative changes of the wrists. Finally, the examiner stated that the Veteran’s diagnosed bilateral radiocarpal joint degenerative arthritis was less likely than not to have manifested during active service or within one year of discharge, as 2011 imaging of the wrists were normal and degenerative changes were not identified on imaging until 2017. His radiocarpal joint disease was more likely than not age related. The Board finds this opinion to be particularly persuasive as it was rendered by a medical specialist, in contemplation of the Veteran’s complete medical history, as well as the Veteran’s own lay assertions, and a physical examination of both of the Veteran’s wrists. The opinions offered include detailed explanations for how the opinions were reached and include citation to known medical principles, as well as evidence in the record. The Board has searched the record but finds no medical evidence or opinions which would contradict the opinion of the 2021 VA examiner. The Board acknowledges the Veteran’s own firmly held beliefs that his variously claimed wrist disabilities are caused by active service. While, lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his bilateral wrist disabilities, especially in light of the VA examiner’s conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of degenerative changes in either wrist in service. See id. Finally, to the extent that his bilateral radiocarpal joint disease falls under the diagnostic umbrella of “arthritis,” there is inadequate evidence of record to support the conclusion that his disability manifested either in service or within one year of separation from service. While the Veteran reported popping in his wrists during service, and has testified to ongoing symptoms since that time, the medical evidence, particularly the 2011 imaging reports, did not find any evidence of degenerative changes as recently as 8 years after separation from service. Indeed, the first actual medical evidence of degenerative changes, which are diagnosed via imaging, occurred in 2017, 14 years after separation. As such, while the Veteran has testified to ongoing symptoms from the time of service, the medical evidence does not support a conclusion that either wrist had arthritis within one year of separation, and service connection on a presumptive basis is not supported in this matter. In sum, the Board finds that the Veteran’s wrist disabilities, claimed as bilateral radiocarpal joint disorders, and right wrist tendonitis, are less likely than not related to any incident of active service. Neither did any of those disabilities manifest to a compensable degree within one year of separation from active service. As such, the claims are denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 4. Entitlement to service connection of hypertension The Veteran seeks service connection of hypertension. The Board finds that the claim should be denied. As an initial matter, the Board recognizes a current diagnosis of hypertension. There are no documentations of hypertension in his service treatment records, nor any evidence of any in-service incident, illness or injury to which the present hypertension could be etiologically linked. Rather, the Veteran asserts that his present hypertension is either caused or aggravated by his service-connected PTSD. The Veteran was afforded a VA examination in August 2016, which acknowledged both his hypertension and his PTSD. The examiner then stated that the Veteran’s hypertension was less likely than not caused by his PTSD, because PTSD is not known to cause permanent elevation in blood pressure to the point that it causes such a diagnosis. Also, a review of his medications taken for his PTSD do not reveal any medications known for causing hypertension. Because that opinion only discussed direct causation, and did not discuss aggravation, the Board remanded this claim so that a new examination could be conducted. He was afforded a new examination in September 2019. Following a thorough physical examination and review of the Veteran’s medical history and lay assertions, the examiner concluded that the Veteran’s hypertension was also less likely than not aggravated by his PTSD. In support of this, the examiner stated that there is no pathophysiological link between PTSD and the development of hypertension, therefore, there can be no aggravation beyond natural progression of hypertension by PTSD. The examiner also confirmed the prior examiner’s conclusion that the Veteran’s PTSD could not have caused the Veteran’s hypertension, also citing to the lack of a pathophysiological link between the two disabilities. The Board finds these opinions to be probative of the questions in this matter. They were given by medical specialists in contemplation of the complete medical record, to include physical examinations of the Veteran and consideration of the Veteran’s own lay statements and assertions. They included reasoned discussions of how the opinions were reached which included citation to known medical principles. The Board has searched the record but finds no medical evidence or opinions which would explicitly overrule or call into question these opinions. The Board does acknowledge the Veteran’s assertion that his hypertension has been caused or worsened by his PTSD, but finds this unpersuasive. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause or aggravation of his hypertension, especially in light of the VA examiner’s conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of hypertension in service in service. See id. The Board also finds that the Veteran’s hypertension was not noted in his service treatment records, nor was there any evidence of elevated blood pressure or a diagnosis of hypertension within one year of separation from active service. As such, the evidence does not support service connection of a presumptive basis. In sum, the Veteran’s hypertension did not manifest in service or within one year of separation therefrom; it is not caused or aggravated by his service-connected PTSD. As such, the claim is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 5. Entitlement to service connection of gastroesophageal reflux disease (GERD) 6. Entitlement to service connection of duodenitis The Veteran has filed claims of service connection of GERD and duodenitis. The Board finds that the claims should be denied. As an initial matter, the Board finds that the duodenitis claim must be denied as failing the primary criteria of service connection, namely, a presently diagnosed disability. The Veteran was afforded a VA examination in February 2016, at which time GERD was diagnosed, but also noted was a 2013 indication of duodenitis in the medical record. Unfortunately, no opinion was given to accompany that examination, and an opinion provided two months later determined that the Veteran did not, in fact, have a diagnosis of GERD or duodenitis. As such, the Board requested a new examination in connection with this claim. In September 2019, the Veteran was afforded an esophageal condition examination, which did confirm the diagnosis of GERD, but did not find a diagnosis of duodenitis. During that examination, the Veteran reported developing duodenitis while stationed at Aberdeen, Maryland, but that it eventually resolved. A follow-up opinion provided by the September 2019 examiner also found a lack of diagnosis for duodenitis at that time or during the period on appeal. To the extent that the Veteran has filed a claim for duodenitis, the Board notes that such a diagnosis is medically complex, and as a lay person, the Veteran lacks the medical expertise to provide such a diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). As the Veteran does not have a present diagnosis of duodenitis, that claim must be denied. Turning to the question of service connection of GERD, the Board recognizes a confirmed diagnosis of known pathology as confirmed by two separate VA examinations. The Veteran has asserted that he first experienced stomach pain on active duty. His service treatment records that are available prior to his second period of active duty do not imply any gastric conditions. However, during deployment in November 2002, he did complain of two weeks of abdominal pain. His post-deployment health assessment noted indigestion, however, his separation examination in August 2003 denied any such issues. The Board notes that, because GERD is a diagnosed condition of known etiology, it cannot me a medically unexplained chronic multisymptom illness (MUCMI), as anticipated by 38 C.F.R. § 3.317. Nonetheless, the Board does acknowledge that the Veteran served in the Southwest Asia theatre, and therefore, an opinion was sought that considered whether his GERD cased caused by any in-service event, to include any exposures in the Persian Gulf. He is also service-connected for residuals of an ulcer, and therefore the question of secondary service connection is also before the Board. As noted above, the Veteran was afforded a VA examination in February 2016 which diagnosed GERD, but did not offer an opinion on the etiology of that disability. An opinion obtained two months later stated that the Veteran does not have GERD and declined to opine on the etiology of such a disability. As such, the Board found the February 2016 examination report probative of the Veteran’s diagnosis, but not of the etiology thereof. Therefore, the claim was remanded for a new examination. In September 2019, a new examination was conducted which confirmed the prior diagnosis of GERD. The examiner reviewed the entire record, to include the Veteran’s service treatment records, non-military treatment records, and lay statements and concluded that the Veteran’s GERD was less likely than not related to any in-service event or exposure. In support of this, the examiner noted that his separation examination in November 1992 did not identify any GERD or related gastrointestinal issues. While a post deployment assessment in July 2003 noted some indigestion, by August 2003, his second separation examination also declined to document any such issues to include a diagnosis of GERD. The examiner also opined that the Veteran’s service-connected ulcer was less likely than not a causative or aggravating factor of the Veteran’s GERD. In support of this, the examiner explained that GERD and ulcers are different pathophysiological conditions, which are generally unrelated to one another. Ulcers are not known to cause or aggravate GERD, and vice versa. The Board finds these opinions persuasive. They were given by a medical specialist in contemplation of the complete medical record, and provided a rationale that applied known medical principles to the facts of this case. The Board has reviewed the medical evidence available, and finds no evidence or opinions which would directly contradict this examiner’s opinions. The Board does acknowledge the Veteran’s firmly held belief that his GERD is related to active service. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his GERD, especially in light of the VA examiner’s conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of GERD in service. See id. In sum, the Board finds that the evidence does not support a finding that the Veteran’s GERD was related to any incident of active service. Likewise, it is not caused or aggravated by his service-connected residuals of an ulcer. As such, service connection of GERD is denied. 7. Entitlement to service connection of arthritis of the right foot The Veteran has claimed service connection of right foot arthritis, which he asserts has been caused by his service-connected right foot fallen arch. The Board finds that the claim should be denied. The Board previously remanded this appeal so that the Veteran could be afforded a VA examination which fully assessed his foot symptoms. The Veteran presented for an examination in September 2019. The examiner took a complete medical history from the Veteran, which included a review of the Veteran’s historical medical records and lay statements regarding symptoms from the Veteran. The examiner also conducted a thorough physical examination of the Veteran’s bilateral feet. The only diagnosis given to account for the Veteran’s right foot symptoms was pes planus, which included his fallen arch. There was no evidence of any arthritis identified in the foot, or any other pathology which could account for his reported symptoms, as confirmed by x-ray images taken on September 13, 2019. The only symptom which the Veteran reported was “restlessness in his right foot when I sleep at night,” which was attributed to his fallen arch. In light of this examination, the Board must deny the Veteran’s claim as failing the primary criteria of service connection – he does not have a present diagnosis of arthritis, or any other foot disability beyond that which is already service connected (fallen arch) and all of his symptoms are attributable and compensated by his fallen arch rating. In this regard, the Board finds the 2019 examination quite persuasive as it was given by a medical specialist following a thorough review of the claims file and a physical examination which included comprehensive diagnostic testing. The Board has reviewed the evidence of record but finds no medical evidence that would contradict the 2019 examiner’s conclusions. The Board does acknowledge the Veteran’s own assertion that he suffers from arthritis of the right foot, but finds it unpersuasive. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, diagnosis of complex disabilities and disfunctions is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make a diagnosis of arthritis in his foot, especially as such a diagnosis requires complex diagnostic testing, and in light of the VA examiner’s conclusions to the contrary to include imaging that failed to diagnose that disability, but rather attributed his symptoms to his already service-connected fallen arch. See id. In sum, the Veteran’s right foot symptoms are all attributable to his service-connected right foot fallen arch, and he does not have a second, separate diagnosis in the right foot which may be granted service connection. The Veteran does not have a diagnosis of duodenitis. As such, the claims are denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 8. Entitlement to service connection of degenerative arthritis of the thoracolumbar spine 9. Entitlement to service connection of left lower extremity peripheral neuropathy The Veteran seeks service connection of a low back disability, diagnosed as arthritis of the thoracolumbar spine. He also seeks service connection of left lower extremity peripheral neuropathy, as a neurological complication of the spine arthritis. The Board finds that the claims should be denied. As an initial matter, the Board recognizes present diagnoses of degenerative joint and disc disease of the lumbar spine, as well as left lower extremity peripheral neuropathy. The Veteran also complained of some low back issued during service. Specifically, there are no notations in his initial period of service, to include his separation examination in November 1992. Post-deployment health assessments in August 2003 noted musculoskeletal issued, but two days later changed that to a history of muscle spasms. The Veteran was afforded a VA examination in March 2016, in which the examiner concluded that the low back disability and left lower extremity peripheral neuropathy were related to active service, because the service treatment records showed evidence of complaints of back pain in service. Unfortunately, no rationale was given for that opinion. The RO sought an addendum opinion the following month. That opinion stated that the Veteran’s service treatment records did not document a low back injury in service, and that there was no continuity of symptoms documented between service and 2011. As such, there was no nexus between the present disabilities and active service. As was addressed in the prior remand, the Board found this opinion similarly unpersuasive as it was based on the premise that there was no evidence of any symptoms in service or since that time, while ignoring the Veteran’s lay statements regarding such symptoms. In September 2019, the Veteran was afforded a new physical examination of his low back. His diagnosis of degenerative arthritis of the spine was confirmed. The examiner then reviewed the evidence of record ans stated that the currently diagnosed arthritis and degenerative disc disease of the spine were less likely than not due to any incident of active service. In support of this, the examiner cited to the general lack of orthopedic issues in the record, whereas muscle spasms were more likely found to be the culprit for his in-service low back pain. There were no imaging reports available during the Veteran’s period of active service, so there was no evidence to prove that his low back diagnoses which were first made in April 2015, were present during service. Further, muscle spasms, as were noted in service, have no pathophysiological correlation to the development of degenerative joint or disc disease of the lumbar spine, as the former is a muscle issue and the claimed conditions affecting the Veteran deal with the boney and disc architecture of the spine. The Board finds this opinion to be persuasive. It was rendered by a medical specialist in contemplation of the complete medical record, and included a discussion of the facts in evidence, and rationale which applied those facts to known medical principles. The Board does acknowledge that the original opinion did favor service connection, but as noted above, that opinion did not provide any type of discussion or rationale for how the conclusion was reached, but rather cited to the Veteran’s service treatment records alone. While both followed a physical examination of the Veteran, when compared to each other, the Board finds the 2019 opinion to be more persuasive. The Board does acknowledge the Veteran’s own firmly held beliefs that his present spinal arthritis is related to active service, but finds this of limited probative value. While the Veteran is competent to report pain in service, that pain has generally been attributed to muscle spasms, which the 2019 examiner has found to be a separate and distinct pathology from the arthritis which was diagnosed in 2015. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his spinal arthritis, especially in light of the VA examiner’s conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of arthritis itself in service. See id. The Board also acknowledges lay statements submitted in 2020 on behalf of the Veteran, attesting to his experiencing back pain in service. However, the Board finds that this evidence is similarly unpersuasive. There is no indication in the record that the Veteran’s fellow service member possesses the medical expertise to opine as to the cause of his present thoracolumbar arthritis. Further, those statements only serve to support that the Veteran experienced back pain throughout service. However, as was noted in the most recent remand, this was an acknowledged fact prior to the 2019 examiner giving their opinion, and there is nothing in the record to indicate that the examiner did not consider such lay evidence. Finally, to the extent that arthritis is a “chronic” disability for presumptive purposes, the Board recognizes that the Veteran has provided competent testimony of back pain during his first period of service, which he asserts has worsened to the present, and thus there is evidence that his arthritis manifested during service. The Board finds this of limited probative value as well. Although he reports back pain in his first period of service of such intensity that he often was required to leave his duty station, which is also asserted in the 2020 buddy statement from his fellow service member, however, once the competency of lay evidence is established, the Board must assess the credibility thereof. His separation examination from his first period of service does not mention any such back problems. Throughout his second period of service, he reported some low back pain which was generally attributed to muscle spasms in August 2003. With symptoms and treatment as significant as those described by the Veteran and others, the Board would expect some type of notation in the service treatment records, particularly his separation examination. Further, despite the Veteran’s assertions of significant back pain throughout service and to the present, there are no private records to confirm such symptoms or diagnoses between separation in 2003, and his eventual diagnosis of arthritis in 2015. Arthritis is a very specific etiology which must be confirmed by diagnostic imaging. There is inadequate evidence in the record to show the Veteran’s arthritis manifested to a compensable degree either in service, or within one year of separation from service. Therefore, service connection on a presumptive basis is also not warranted. Finally, there is no evidence in the record of any specific neurological symptoms or diagnoses during active service, and to the extent that the Veteran’s lower extremity peripheral neuropathy has been shown to be a neurological complication of his low back disability, as the Board has denied service connection of the spine disability, the claim for peripheral neuropathy must also be denied. In sum, the Board finds that the Veteran’s thoracolumbar spine arthritis and degenerative disc disease, with associated left lower extremity peripheral neuropathy, did not have onset during or within one year of separation from service. It is not otherwise related to any incident of active service, to include the Veteran’s in-service muscle spasms. Therefore, the claims are denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. REASONS FOR REMAND 10. Entitlement to service connection of a bilateral hip condition A remand by the Board gives a claimant a right to compliance with the orders contained therein. The Board errs as a matter of law when it fails to ensure strict compliance with its own remand orders. Stegall v. West, 11 Vet. App. 268 (1998). Inasmuch as the Board regrets any further delay in the final adjudication of the Veteran’s bilateral hip claim, an additional remand is necessary. In its prior remand, the Board noted that the Veteran had complained of multiple joint pain throughout service, and although not explicitly indicating hip pain at the time, now asserts that he did experience such pain in service. As such, the Board requested opinions on a direct and secondary basis (secondary to his service-connected foot disability). While secondary service connection opinions were offered, the examiner did not provide an opinion with regard to direct service connection, as was ordered by the Board. Therefore, an addendum opinion must be obtained which satisfies the Board’s prior remand orders. The matters are REMANDED for the following action: 1. Invite the Veteran to submit any additional evidence in support of his claim. 2. Obtain an addendum opinion from an appropriate clinician to determine the etiology of the Veteran’s present bilateral hip arthritis. The examiner should consider the Veteran’s complete medical record, including his reports of multiple joint pain in service, as well as his lay statements regarding injuries to his hips, and pain since service. The examiner should then state whether it is at least as likely as not that the Veteran’s bilateral hip arthritis was due to any incident of active service. The examiner should also state whether the Veterans arthritis had onset during active service, or within one year of separation from service. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Pryce, Counsel