Citation Nr: 25005185 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 18-17 603 DATE: April 16, 2025 ORDER Service connection for a back disability is denied. Service connection for a right wrist disability is denied. Service connection for a left wrist disability is denied. FINDINGS OF FACT A back disability and bilateral wrist disorder were not shown contemporaneous with service or for many years thereafter and they are not shown to be causally or etiologically related to any disease, injury, or incident in service.? CONCLUSIONS OF LAW 1. The criteria for service connection for a back disability have not been met.? 38?U.S.C. §§ 1110, 5107; 38?C.F.R. §§ 3.303, 3.307, 3.309.? 2. The criteria for service connection for a right wrist disability have not been met.? 38?U.S.C. §§ 1110, 5107; 38?C.F.R. §§ 3.303, 3.307, 3.309.? 3. The criteria for service connection for a left wrist disability have not been met.? 38?U.S.C. §§ 1110, 5107; 38?C.F.R. §§ 3.303, 3.307, 3.309.? REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Air Force from May 1992 to March 1993, from September 17, 2001 to September 30, 2001, from March 2002 to September 2002, from November 2002 to May 2003, from May 2004 to September 2004, and from January 2011 to October 2011. The Veteran also had additional Reserve Component service and his service included service in the Southwest Asia (Iraq) during the Persian Gulf War. In July 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. At the hearing, the Veteran clarified that he was claiming service connection for a bilateral wrist disability. The Board has therefore recharacterized the issues on appeal as they appeal above to more accurately reflect the Veteran's contentions. In October 2021the Board of Veterans' Appeal (Board), among other things, denied the above claims. The Veteran appealed the October 2021 Board decision to the United States Court of Appeals for Veterans Claims (Court). In an October 2022 order, which incorporated the parties September 2022 Joint Motion for Partial Remand (JMPR), the Court vacated and remanded the October 2021 Board decision to the extent that it denied the above claims. In January 2023 and July 2024 the Board remanded the appeal for additional development to address the concerns of the Court. Based on the history of development of this appeal and the fact that with each prior remand additional development has provided overall negative evidence against the claims denied herein, the Board finds there has been substantial compliance with prior remand directives and the post-Remand development addressed the concern raised by the JMPR such that that a third remand for more development would likely not be productive of evidence beneficial to the Veteran's claims. Further remands are not warranted. Substantial compliance with the 2023 and 2024 Board's remand orders is demonstrated. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). See 38 U.S.C. § 5103; Barr v. Nicholson, 21 Vet. App. 303 (2007); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service.??38?U.S.C. § 1131;?38?C.F.R. §?3.303.? Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein.??38?C.F.R. §?3.303(a). 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).???????? To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or "nexus" between the present disability and the disease or injury incurred or aggravated during service.? Horn v.? Shinseki, 25?Vet. App.?231, 236 (2010);?Shedden?v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004);?Gutierrez v.?Principi, 19?Vet. App.?1, 5 (2004) (citing Hickson v.?West, 12?Vet. App.?247, 253 (1999)).? In many cases, medical evidence is required to meet the requirement that the evidence be "competent."? However, when a disability may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation.? Barr v. Nicholson, 21?Vet. App.?303, 309 (2007).???????? Service connection for certain chronic diseases?may be presumed to have been incurred in service by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38?U.S.C. §§?1101, 1112;?38?C.F.R. §§?3.307(a)(3), 3.309(a).? Such a chronic disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service.??38?C.F.R. §§?3.307(a). When a chronic disease is shown in service, sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes.??38?C.F.R. §?3.303 (b).? To be "shown in service," the disease identity must be established, and the diagnosis must not be subject to legitimate question.??Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013);?see also 38?C.F.R. §?3.303(b).? There is no "nexus" requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease.? Walker, 708 F.3d at 1336.???????? Service connection may also be granted on a secondary basis for a condition that is not directly caused by the?Veteran's service.? 38?C.F.R. §?3.310.? In order to prevail under a theory of secondary service connection, the evidence must demonstrate an etiological relationship between (1) a service-connected disability or disabilities and (2) the condition said to be proximately due to the service-connected disability or disabilities.? Buckley v. West, 12?Vet. App.?76, 84 (1998); see also?Wallin?v. West, 11?Vet. App.?509, 512 (1998).? In addition, secondary service connection may also be found in certain instances when a service-connected disability aggravates another condition. ?See Allen v. Brown,?7?Vet. App.?439 (1995);?38?C.F.R. §?3.310 (b); see also Spicer v. McDonough, No. 2022-1239 (Fed. Cir. March 8, 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection).????? Next, the Board notes that the Court in Joyner v. McDonald, 766 F.3d 1393, 1395 (Fed. Cir. 2014) held, in part, that the Board needs to always consider 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 in cases where the Veteran has served in the Persian Gulf, since August 2, 1990. See also 38 C.F.R. §3.320. In this case, the Veteran is a qualifying "Persian Gulf veteran" as defined by law. 38 C.F.R. § 3.317(e). In this regard, he has service in Southwest Asia in support of the first Persian Gulf War. Therefore, the Board finds that it is also required to consider 38 C.F.R. §§ 3.317 and 3.320 in this claim. Service connection and the laws and regulations surrounding presumptive service connection for Southwest Asia service and Persian Gulf War claims have become increasingly complex. First the Board notes service connection may be established on a presumptive basis for a veteran with qualifying service who exhibits objective indications of a qualifying chronic disability provided that it became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2026, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38?U.S.C. §?1117; 38?C.F.R. §?3.317(a)(1). To fulfill the requirement of chronicity for the presumption of service connection, the illness must have persisted for a period of six months. 38?C.F.R. §?3.317(a)(4). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): an undiagnosed illness, a medically unexplained chronic multi symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or any diagnosed illness that the Secretary determines warrants a presumption of service-connection. 38?U.S.C. §?1117; 38?C.F.R. §?3.317. "Objective indications" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. 38?C.F.R. §?3.317(a)(3). Signs or symptoms that may be a manifestation of an undiagnosed illness ora chronic multi symptom illness include the following: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, menstrual disorders. See 38?U.S.C. §?1117; 38?C.F.R. §?3.317(b). The term medically unexplained chronic multi symptom illness means 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. 38?C.F.R. §?3.317(a)(2)(ii). The Board notes that, effective July 13, 2010, VA amended its adjudication regulations governing presumptions for Persian Gulf War veterans under 38 C.F.R. § 3.317(a)(2)(i)(B) to clarify that chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome are examples of medically unexplained chronic multi symptom illnesses and are not an exclusive list of such illnesses. See 75 Fed. Reg. 61997 (Oct 7, 2010). A second type of presumption is available for veterans with qualifying service under 38 C.F.R. § 3.320, from August 5, 2021, when VA regulations were amended to establish presumptive service connection for three chronic respiratory health conditions, i.e., asthma, rhinitis, and sinusitis, to include rhinosinusitis, in association with presumed exposures to fine, particulate matter. See 75 Fed. Reg. 42724 (Aug. 5, 2021). The listed diseases shall be service connected if manifested to any degree within 10 years from the date of separation from military service. 38 C.F.R. § 3.320(a)(1) (2021). On September 1, 2023, VA issued a final rule revising 38 C.F.R. § 3.320, with an effective date of October 31, 2023, and among other things, removed the 10-year manifestation requirements for asthma, rhinitis, and sinusitis (to include rhinosinusitis). See 88 Fed. Reg. 169, 60336 (Sep. 1, 2023). Additionally, effective April 26, 2022, VA issued a final rule revising 38 C.F.R. § 3.320 to also establish presumptive service connection for Veteran's with qualifying period of military service for nine rare respiratory cancers in association with presumed exposure to fine particulate matter. See 87 Fed. Reg. 24421 (Apr. 26, 2022). These cancers are presumed as due to exposure to fine particulate matter if manifested to any degree at any time following separation from a qualifying period of military service: squamous cell carcinoma of the larynx, squamous cell carcinoma of the trachea, adenocarcinoma of the trachea, salivary gland-type tumors of the trachea, adenosquamous carcinoma of the lung, large cell carcinoma of the lung, salivary gland-type tumors of the lung, sarcomatoid carcinoma of the lung, typical and atypical carcinoid of the lung. 38 C.F.R. § 3.320(a)(3). Finally, on August 10, 2022, President Biden signed the Sergeant First Class (SFC) Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022, also known as the PACT Act, into law. See Pub. L. 117-168. The PACT Act establishes additional presumptions of in-service exposure to burn pit and other environmental hazards for qualifying service in the Persian Gulf. Relevant to Southwest Asia claims, the PACT Act, among other things, added more than 20 burn pit and other toxic exposure presumptive conditions for Gulf War era and post-9/11 veterans including brain cancer, gastrointestinal cancer of any type, glioblastoma, head cancer of any type, kidney cancer, lymphatic cancer of any type, lymphoma of any type, melanoma, neck cancer of any type, pancreatic cancer, reproductive cancer of any type, and respiratory (breathing-related) cancer of any type, as well as asthma that was diagnosed after service, chronic bronchitis, chronic obstructive pulmonary disease (COPD), chronic rhinitis, chronic sinusitis, constrictive bronchiolitis or obliterative bronchiolitis, emphysema, granulomatous disease, interstitial lung disease (ILD), pleuritis, pulmonary fibrosis, and sarcoidosis. Importantly, under the PACT Act, VA must provide the veteran with a medical examination that considers service connection for a claimed disability as due to a toxic exposure in situations where there is (a) evidence of a disability, (b) evidence of participation in a toxic exposure risk activity (TERA), and (c) not enough evidence to establish service connection for the disability. 38 U.S.C. § 1168(a). However, no examination is required if the Secretary has determined there is no indication of an association between the claimed disability and a TERA. 38U.S.C. § 1168(b). Tellingly, while the PACT Act amendment is not effective until October 1, 2026, in an Executive Decision Memorandum (EDM) dated September 20, 2022, VA adopted the Office of General Counsel's interpretation of the PACT Act and VA has, in substance, added the above conditions to the list of presumptive disorders due to burn pit and other toxic exposure without waiting for the 2026 phase-in date. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA.? VA shall consider all information and medical and lay evidence of record.? Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant.? 38?U.S.C. §?5107; 38?C.F.R. §?3.102; see also Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).????? 1. Entitlement to service connection for a bilateral wrist disability. 2. Entitlement to service connection for a back disability. The Veteran seeks service connection for a bilateral wrist disability and a back disability. He contends that his current back and bilateral wrist disorders were caused by general wear and tear incurred in the performance of his duties as a civil engineer during service. Considering the Veteran's contention, references to the PACT Act have no application of this case. However, as this case have been to the Veteran's Court, several different, inconsistent, contentions have been made (and will be addressed below), the Board believes it must address all issues: The Pact Act has no application of this case at all. The contentions of the Veteran and their representative support this finding. Notwithstanding, the Board will address the evidence that has been obtained in this case. The Veteran described engaging in construction work and plumbing work that involved a lot of manual labor, climbing and crawling. Reportedly, he was treated in service for the claimed disorders with muscle relaxers and with icing. The Veteran reported using bilateral wrist braces and occasionally using a back brace for lifting. He asserts that his bilateral wrist pain at times interfered with the performance of his civilian duties such as heavy lifting, wielding a wrench and fitting pipes at work. Most recently, concerning the back disability, the Veteran's representative argued in a March 2025 Brief that the Veteran's service connected posttraumatic stress disorder (PTSD) resulted in him becoming obese, which, he claims, in turn, caused his claimed osteoarthritis of the spine. In support of the claim, the representative pointed to a November 2020 PTSD examination report wherein the Veteran reported either undereating or overeating, as well as having an alcohol problem, although his alcohol consumption was largely under control. The concept of obesity as an "intermediate step" in the service-connection context was recently addressed by the Court of Appeals for Veterans Claims (Court) in Garner v. Tran, 33?Vet. App.?241 (2021).?? In Garner, the Court observed that in January 2017, VA's Office of General Counsel (OGC) issued a precedential opinion, finding that although obesity cannot be service connected on a direct basis, obesity may serve as an intermediate step between a service-connected disability and a condition claimed on a secondary basis.? VAOPGCPREC 1-2017.? To decide such claims, OGC stated the analysis involves addressing the following questions: (1) whether the service-connected disability caused the veteran to become obese; (2) if so, whether obesity, as a result of the service-connected disability, was a substantial factor in causing the claimed secondary disability; and (3) whether the claimed secondary disability would not have occurred but for obesity caused by the service-connected disability. Id.? The Court acknowledged that the soundness of OGC's guidance was endorsed in its decision in Walsh v. Wilkie, 32?Vet. App.?300, 305-07 (2020).? However, the Court noted that neither OGC's opinion nor Walsh provided guidance regarding what factual circumstances would give rise to claims for secondary service connection with this theory of entitlement.? The Court provided the following non-exhaustive list of considerations that could give rise to a reasonably raised theory of secondary service connection with obesity as an intermediate step: (1) mobility limitations or reduced physical activity as a result of a service-connected physical disability (in particular, orthopedic conditions or chronically painful conditions); (2) reduced physical activity or inability to follow a course of exercise or diet as a result of service-connected mental disability; (3) side effects of medication (e.g., weight gain), where the medication is prescribed for a service-connected disability; (4) treatise evidence suggesting a connection between all or some combination of obesity, service-connected disability, and the claimed condition; (5) lay statements by a veteran attributing weight gain or obesity to the service-connected disability; and (6) statements by treating physicians or medical examiners attributing weight gain or obesity to the service-connected disability. Id. at 248.? The service treatment records show that in an August 2004 Post Deployment Health Assessment the Veteran endorsed a history painful joints and back pain. The remainder of the service treatment records fail to document a back or wrist disability. On numerous physical examinations and reports of medical history during active duty service and Reserves service, including in September 1991, November 1997, October 2005, May 2010, August 2011 and May 2012, the Veteran denied a history of wrist pain, back trouble, recurrent back pain or any back problems, and his spine and upper extremities were clinically evaluated as normal. At this point, it is the Veteran himself that provides evidence against their own claims. Such important evidence can not be ignored by the Board and must be found to provide highly probative factual evidence against these claims. The service treatment records lack the combination of manifestations sufficient to identify a chronic wrist and/or back disability, as distinguished from merely isolated findings. Rather, the record suggests that the in-service complaints appear to have been transitory in nature and to have resolved over time. The Veteran's own statements during this time support this finding. After service, treatment records in April 2014 reflect complaints of multiple joint pain, including wrist pain, along with an assessment of arthralgia, possibly due to osteoarthritis and fibromyalgia. June 2014 and October 2014 treatment notes indicated that the Veteran had an assessment of rheumatoid arthritis and fibromyalgia treated with medication. A clinician in February 2015, noted multiple joint pain treated for fibromyalgia with medication. VA treatment records since 2017, noted complaints of low back pain. VA treatment records since 2020 noted multiple joint pain arthritis. VA treatment records throughout the appeal reflect that the Veteran's body mass index (BMI) was over 37, indicative of obesity. The Veteran was repeatedly advised to diet and exercise, to include daily walking. The Veteran was offered a referral to a VA weight loss program. There is no indication in this record that the Veteran accepted this help to lose weight. Rather, the evidence shows the Veteran refused to participate in the program. Therefore, arthritis was not shown in service or within one year following discharge from active duty service, as such, service connection cannot be established on a presumptive basis.? 38?U.S.C. §?1112; 38?C.F.R. §§?3.307, 3.309.???? More importantly, the record does not show that the?Veteran?had a continued problem?with the back or wrists in and since service.? The Board notes that the first documented evidence of back and wrist complaints was initially noted more than one year after the Veteran's discharge from his last period of active duty service in October 2011.? In so noting, the Board recognizes that the mere absence of medical records is not dispositive as to the question of continuity; the lay evidence must be considered as well.? See Buchanan v. Nicholson, 451 F.3d at 1335.? If, however, it is determined based on reliable evidence, that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service.? see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).? To the extent the Veteran asserted continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record, to include the service treatment records and post service treatment records.? Thus, the Veteran did not adequately show that his post-service complaints of back and/or wrist symptoms continued in and since service.???? In reaching the above conclusion, the Board does not rely solely on the absence of contemporaneous evidence corroborating the Veteran's reports of continuity. Instead, there is evidence in the service treatment records, to include multiple reports of medical history and medical examination reports, wherein the Veteran affirmatively denied any back and/or wrist problems, and that the Veteran's back, upper extremities were clinically evaluated as normal and no back or wrist problems were reported. It is also noteworthy that prior to filing of a claim for VA benefits, there is no evidence of in-service trauma or reports of symptoms in and since service. More importantly, the Veteran has provided inconsistent statements regarding the onset of his claimed disorders. At the Board hearing in June 2021, the Veteran attributed his back and bilateral wrist problems to the general wear and tear during the performance of his duties in service, while at a VA examination in February 2024, the Veteran reported injuring both wrists during his first deployment when he jumped over a ditch and fell on both hands and wrists. Reported onset of back pain in 2005, following a motor vehicle accident (MVA) during deployment in 2003, appears also to be indicated. The Board places greater evidentiary weight on the affirmative denials issued by the Veteran many years prior to the filing of his service connection claims, than later statements alleging continuity of symptoms since service, which are internally inconsistent and may be influenced by pecuniary interest in obtaining VA benefits. See Cartwright v. Derwinski, 2?Vet. App.?24, 25 (1991) (pecuniary interest may affect the credibility of testimony); see also Caluza v. Brown, 7?Vet. App.?498, 510-511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the testimony). The Veteran's recollection of events from so many years ago appears to be clearly in error and is so found by the Board. On the question of a nexus between the current back disability and/or bilateral wrist disorders, initially noted many years after service, and service, the evidence weighs against the claims.?? On VA examination in February 2024, the Veteran reported injuring both wrists during his first deployment when he jumped over a ditch and fell on both hands and wrists. Reportedly, he was evaluated and was placed on muscle relaxers and given one day off work. The Veteran reported pain and swelling in both wrists. He had constant pain that ranged from 5/10 to 7/10 (10 being the worst pain). He treated his symptoms with medication and used wrist sleeves. Pain was worsened with flexion and extension, such as when he was at work. Range of motion in both wrists was limited. The examiner found that there was no evidence of persistent/recurrent symptoms or concerns for a diagnosis of a wrist disability that had onset in service. Concerning the back condition, the Veteran reported onset of back pain in 2005, following a MVA during his deployment in 2003. He described being ejected from the vehicle. He was evaluated for the condition and given muscle relaxers. His back pain was dull and constant rated as 7-8/10. He treated his symptoms with topical and oral medication. Range of motion was reduced. The examiner opined that the Veteran's claimed back disability and bilateral wrist disorders were less likely than not caused by service, including the indicated TERA, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran, including his service in Southwest Asia and exposure to gas, fine particulate matter, biohazardous materials and dust. The examiner explained that there was no medical or scientific evidence available that identified a causal relationship between the TERA(s) and the development of the claimed back and/or wrist disability. Additionally, his symptoms of back and/or wrist pain with motion did not qualify as an undiagnosed illness because an undiagnosed illness diagnosis required replicable objective findings capable of independent verification that were not accounted for by another clinical condition. In an addendum opinion report in March 2024, the VA examiner indicated that a review of the evidence showed that the Veteran osteoarthritis of the spine, left wrist and right wrist, initially diagnosed in 2014, three years after the Veteran's last period of active duty service. Therefore, it was less likely than not that the claimed condition of back disability was incurred in or caused by military service. Additionally, arthritis was a disease with a clear and specific etiology. Spine osteoarthritis was a primary source of chronic low back pain. The examiner noted that joint injuries, with or without associated articular surface disruption, could lead to a progression in arthritis and degenerative changes. Degenerative changes and post-traumatic type arthritis could occur at any age and could result from any type of physical trauma such as sports, MVA, fall, or injury. Additionally, different studies showed that joint injuries substantially increased the risk of developing osteoarthritis. Studies had shown that a range of 20-50% of people who had a joint trauma developed osteoarthritis. There was no medical or scientific evidence available that identified a causal relationship between an exposure event in Southwest Asia and the development of the claimed condition of back and/or wrist disability. A nexus has not been established. In January 2025, a VA medical opinion addressing the claims was obtained. Following a review of the claims file, the examiner opined that the right and left wrist disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness, to include TERA. The examiner noted that the service records for the period failed to show evidence of chronicity of care, continuity of symptoms or pathology for an orthopedic wrist condition. At the Board hearing, the Veteran testified that here was not a specific injury but just general wear and tear. He indicated at that time, that he had trouble with his wrists doing plumbing work while on active-duty. Treatment records showed that Veteran's post active-duty occupation involved the same type of activities the Veteran did during active duty service, except he had been doing for much longer in his civilian occupation. The bilateral wrist disabilities were manifested by subjective complaints of pain with motion and limited range of motion. The Veteran's reports of chronicity were contradicted by the service and post-service treatment records. The examiner found the service and post service treatment records, which initially documented any wrist complaints several years after the Veteran's last period of service and well after one year from release of active duty more probative in finding that his wrist condition had onset post service discharge and was unrelated to service than the Veteran's reported medical history. Concerning the back disability, following a review of the claims file, the examiner opined that the back disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, to include TERA. At the Board hearing, the Veteran testified that here was not a specific injury but just general wear and tear. The examiner noted that the service treatment records for the periods of active duty service failed to show evidence of chronicity of care, continuity of symptoms or pathology for orthopedic vertebrae which could in turn lead to the minimal degenerative changes seen on x-ray post service discharge. The examiner attributed the degenerative changes seen on imaging studies to age-related changes, as well as obesity. Obesity could cause mechanical shear forces on the low back which could cause arthritic changes. The examiner added that the Veteran's obesity was a condition entirely separate and unrelated to his service connected disabilities and therefore not caused or aggravated by them. The examiner explained that obesity was primarily due to consuming more calories than the body burned off. Weight loss was due to a negative net of calories. A negative net of calories could be achieved with diet alone or with diet and exercise. An orthopedic or mental health condition did not preclude all forms of exercise as there were paraplegics who were not obese. The examiner noted that the Veteran was clearly able to lose weight and exercise despite the service connected disabilities. Obesity would have occurred regardless of his service connected disabilities as obesity was due to consuming more calories than the body needed. With regards to the Veteran's TERA, the examiner indicated that there was no evidence int the medical literature to support a causal relationship between degenerative arthritis of the lumbar spine and environmental hazards, chemicals of interest or the toxins noted on TERA or ILER. Degenerative arthritis had a clear diagnosis and etiology and was due to aging, general wear and tear or in certain cases obesity or past trauma. The Board finds the opinions of the VA examiners to be highly persuasive and probative in finding that the evidence does not support a conclusion that the Veteran incurred the current back disability or bilateral wrist disorder in service, to include as due to his TERA.? The examiners' findings were based on a review of the evidence, including the service and post service treatment records, in addition, the 2024 VA examiner interviewed and examined the Veteran. The examiners considered the complete record and the Veteran's contentions and provided an explanation as to why the evidence does not support a finding that his back and bilateral wrist disabilities were due to service, to include trauma incurred therein and TERA.? Finally, the VA examiners' opinions were internally consistent and consistent with other evidence of record and are of significant probative value.? Accordingly, the VA examiners' opinions are entitled to great probative weight.? See Nieves-Rodriguez v. Peake, 22?Vet. App.?295, 303-304 (2008).? Significantly, there is no competent medical opinion of record linking the current back and/or wrist disability to any aspect of the Veteran's service.????? To the extent that the Veteran's representative argued for service connection on a secondary basis with obesity as an intermediate step between his service-connected disabilities and the claimed back disability, the evidence weighs against the claim. While the Veteran's representative asserted that the Veteran's service connected psychiatric disorder caused him to overeat, thereby causing his weight gain and thus leading to arthritis of the spine, there is no indication that the Veteran is incapable of performing any meaningful exercise or, more importantly, incapable of a diet that would reduce his weight, which resulted in obesity.? It is notable that the treatment records throughout the appeal show that the Veteran was capable of exercise, including walking.? ?In this regard, it is notable that the Veteran's treating physicians throughout the pendency of the appeal have consistently counseled the Veteran to reduce his caloric intake and have encouraged exercise as a means of managing his weight. Significantly, to the extent the VA examiner in 2025 attributed the Veterans back disability, in pertinent part, to the natural process of aging as well as obesity, the specifically found that the Veteran's obesity was not caused or aggravated by the Veteran's service connected physical and/or mental health disabilities. The examiner explained the causes of weight gain and the role of dieting and exercise as a means to reduce weight. The VA examiner provided detailed and through explanation in support of the opinion rendered cited to the medical literature and provided adequate rationale for the conclusions reached. See Nieves-Rodriguez, 22 Vet. App. at 304. Significantly, there is no competent medical opinion of record linking the Veteran's obesity to a service connected disability. Although the Veteran may believe?that he acquired his back disability and bilateral wrist disorders in service, and he is certainly competent to report as to the observable symptoms he experiences and their history, he cannot diagnose a back or wrist disability because of the medically complex nature of such diagnoses.? Layno v. Brown, 6?Vet. App.?465 (1994); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).? The ultimate questions in this case are related to an internal medical process which extends beyond an immediately observable cause and effect relationship.?Id.? Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to any injuries incurred therein, is a matter that requires medical expertise to determine.? See Clyburn v. West, 12?Vet. App.?296, 301 (1999) ("although the Veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with.").? The Board finds that the specific, reasoned opinion of the VA examiners of greater probative weight than the more general lay assertions in this regard.? The examiners have training, knowledge, and expertise on which they relied to form the opinions, and the examiners provided rationale for the conclusions reached.? As noted, there is no competent medical evidence that supports the claims.????? Simply stated, both the best medical evidence in this case, and the facts of this case, provide highly probative evidence against the claims, indicating problems that began many years after service with no connection to service.??? In summary, there is no competent evidence of arthritis of the back or wrist or any other chronic disorder in service or within one year following discharge from service.? Thus, the provisions regarding continuity of symptomatology are not applicable.? See Walker, 708 F.3d at 1340.? Moreover, the most probative and persuasive evidence is against a finding that his current back disability and bilateral wrist disorders are related to service. Given the foregoing, the Board finds that the most persuasive evidence is against the claims for service connection and the claims must be denied.? See 38?U.S.C. §?5107(b); Lynch, 1?Vet. App.?at 55-56.?? John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Azizi, T. 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.