Citation Nr: 0002062 Decision Date: 01/27/00 Archive Date: 02/02/00 DOCKET NO. 97-06 714A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for residuals of a right knee injury. 4. Entitlement to service connection for headaches claimed as residual of head injury. 5. Entitlement to service connection for tinnitus claimed as residual of head injury. 6. Entitlement to service connection for residuals of bilateral shoulder injuries. 7. Entitlement to service connection for residuals of a left ankle injury. 8. Entitlement to service connection for a left elbow injury. 9. Entitlement to service connection for residuals of a low back injury. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD G. A. Wasik, Associate Counsel INTRODUCTION The veteran served on active duty from April 1968 to March 1971. This matter is before the Board of Veterans' Appeals (Board) on appeal of a March 1996 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In March 1996, the RO denied the claims of entitlement to service connection for PTSD, hearing loss, a right knee condition, headaches, tinnitus, dislocated shoulders, left ankle condition claimed as ligaments of the left ankle, fracture of the left elbow and a back condition. The veteran has perfected appeals for all the issues denied by the March 1996 rating decision. The Board notes the veteran raised the issue of entitlement to service connection for a right elbow condition at the time of his August 1997 RO hearing. The RO denied entitlement to service connection for a right elbow disability in a supplemental statement of the case dated in May 1998. The veteran's representative expressed disagreement with this decision in a statement received at the RO in November 1998. The RO has not issues a statement of the case in response to the notice of disagreement, and this issue must be remanded to the RO for the issuance of such a statement of the case. 38 U.S.C.A. § 7105; see Manlincon v. West, 12 Vet. App. 238 (1999); Tablazon v. Brown, 8 Vet. App. 359, 361 (1995) (the filing of a notice of disagreement initiates the appellate process) see also Ledford v. West, 136 F.3d 776 (Fed. Cir 1998); Collaro v. West, 136 F.3d 1304 (Fed. Cir. 1998); Buckley v. West, 12 Vet. App. 76 (1998). FINDING OF FACT The claims of entitlement to service connection for post- traumatic stress disorder, bilateral hearing loss, residuals of a right knee injury, headaches claimed as residual of head injury, tinnitus claimed as residual of head injury, residuals of bilateral shoulder injuries, residuals of a left ankle injury, a left elbow injury and for residuals of a low back injury are not supported by cognizable evidence showing that the claims are plausible or capable of substantiation. CONCLUSION OF LAW The claims for service connection for post-traumatic stress disorder, bilateral hearing loss, residuals of a right knee injury, headaches claimed as residual of head injury, tinnitus claimed as residual of head injury, residuals of bilateral shoulder injuries, residuals of a left ankle injury, a left elbow injury and for residuals of a low back injury are not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION Factual Background Review of the service medical records shows that the veteran was found to be without defects at the time of the service entrance examination conducted in March 1968. On audiological evaluation in March 1968, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -5 -10 -10 Not reported 40 LEFT -5 -10 -10 Not reported 25 On a document dated in February 1969, the veteran included a notation that he had been hospitalized for observation of a head injury as a result of a football injury in 1968. In July 1969 the veteran reported that he was having problems with his left shoulder for several weeks. Physical examination revealed a full range of motion. No diagnosis was made. An X-ray of the left shoulder conducted in July 1969 was interpreted as possibly showing some widening of the acromioclavicular joint but the widening could only been seen definitely by comparative weight bearing films. Other than the above, the X-ray did not appear to be remarkable. Comparative weight bearing X-rays were not associated with the claims file. In September 1969 it was noted that the veteran injured his right knee playing football. A diagnosis of knee sprain was made. A separate treatment record dated in September 1969 included the notation that the veteran had injured his right foot playing football. No diagnosis was made. A July 1970 examination resulted in the finding that it was ok for the veteran to play football. In August 1970, the veteran sought treatment for an injury to his left elbow. He reported that the elbow was injured playing football. An X-ray of the elbow did not reveal any fracture. The elbow was put in a cast. A cast on the left elbow was removed in September 1970. The elbow at that time was stiff and painful. On the report of a separation examination conducted in November 1970, no abnormalities with the exception of a scar on the right hand were noted. On audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -5 -5 -10 30 30 LEFT 5 -10 -10 10 15 On a clinical record dated in December 1970, it was noted that the veteran had injured his left elbow three months prior. He developed synovitis and recurring swelling and pain. Physical examination revealed no significant clinical findings. The impression was contusion of the left elbow. An X-ray of the left elbow conducted in December 1970 was interpreted as revealing no significant abnormalities. It was noted on the X-ray report that the veteran had injured the left elbow in August 1970. On a Statement of Medical Condition dated in March 1971, the veteran reported that there had been no change in his medical condition since his separation examination conducted in November 1970. Private treatment records from St. David's Hospital dated in October 1995 have been associated with the claims file. The veteran sought treatment for discomfort in the left wrist, arm, shoulder and chest. He indicated that the onset of the pain began within the preceding year. He also complained of some difficulty with his low back. He denied a history of nervous conditions. Physical examination of the extremities was basically negative throughout with the exception of the left arm, which the veteran the veteran reported was painful. There was a full range of motion of the arm except for gross internal rotation of the arm, which produced some discomfort. The diagnosis was severe left carpal tunnel syndrome. Treatment records from the Austin Diagnostic Clinic dated from August to October 1995 are of record. A clinical record dated in August 1995 included the notation that the veteran had some discomfort in the shoulders bilaterally which would most likely be degenerative disease and a possible rotator cuff injury. X-rays of the shoulders were taken in August 1995. They did not reveal any acute abnormalities. Mild degenerative changes with minimal marginal spurring along the inferior margin of the humerus were present and moderate degenerative changes were seen at both acromioclavicular joints with irregularity and bony atrophy. No soft tissue calcification was noted. X-rays of the cervical and lumbosacral spine were conducted in September 1995. The impression from the cervical spine X-ray was developmental variation in the lower endplates of C-6 and C-7 of uncertain clinical significance. No fracture or dislocation was observed. The facet joints were normal and the neural foramina appeared intact. The impression from the lumbosacral spine X-ray was interesting developmental variation in the lower endplates of the lumbar vertebral bodies which was quite similar to that seen in the lower cervical spine. This was unlikely to represent pathologic change because of its very uniform distribution and smooth contours. Spina bifida occulta of S1 was an incidental finding. Physical examination conducted in October 1995 resulted in an impression of back and chest pain. It was the examiner's opinion that the pain really sounded mechanical in its precipitating factors and nature. It also sounded to the examiner as if the veteran had some type of nerve compression. The transcript of an August 1997 hearing before a hearing officer at the RO has been associated with the claims file. The veteran testified that he was informed that he had hearing loss during active duty while stationed at Fort Rucker, Alabama. He reported that the hearing loss began after sustaining a concussion playing football. He testified that after service he continued to have hearing tests that evidenced hearing loss over the years. He also testified that he recently had a hearing test at the outpatient clinic in Austin. He reported that he had injured his right knee and ankle playing football in approximately 1969. He continued to have problems with his knee post-service. He further related that surgeries were conducted in Austin, Texas. He also related that he had been treated by his family physician, Dr. R., since 1974 or 1975. The veteran reported he would obtain the treatment records from his family physician. He had a large cyst removed from the back of his knee. He testified that his headaches began after sustaining a concussion playing football in 1968. He also experienced memory loss at that time. He was hospitalized for approximately two weeks after the concussion at Fort Rucker. He continued to have problems with headaches after the hospitalization. Post-service he was treated by Dr. R. for headaches. The veteran testified that his tinnitus began in the first part of 1969 while he was stationed in Germany. The ringing in his ears has been constant since his discharge from active duty. He had been exposed to loud noises subsequent to his discharge. He testified that he injured his shoulders playing football and also in a truck accident in approximately 1969. He has received post-service treatment for his shoulder injuries. He also injured his elbows during the reported in-service truck accident and playing football. His left elbow was treated by casting for four weeks during active duty. He had had problems with his elbows since active duty. His elbow was scraped in 1972 or 1973 by a specialist in Austin. He testified he had injured his back, shoulders and neck when he was thrown out a second story window while stationed in Germany in March 1971 just prior to his release from active duty. He did not know if there was an official report made regarding the incident. He reported that he had received medication for his back from the dispensary during active duty. He had not been diagnosed with PTSD. He also reported that he sought treatment for his back injury within one week of discharge. He testified that he would obtain those treatment records. The report of a February 1998 spine examination has been associated with the claims files. The veteran reported that he injured his back in 1970, when he was thrown out a window. An X-ray of the lumbosacral spine was interpreted as revealing early minimal disc space narrowing at L4-5. Degenerative joint disease could not be excluded. The diagnosis from the examination was chronic lower back pain, back injury in 1970, and minimal early degenerative joint disease at L4-5. The veteran was afforded a VA PTSD examination in February 1998. He reported being thrown out a second story window by eight soldiers. The men approached the veteran while he was asleep, took him to a window and threatened him. He did not believe his attackers would throw him out. He landed in snow and was treated at the dispensary. He reported that he filled out an incident report but it was his word against his attackers. The examiner found the veteran did not meet the diagnostic criteria for PTSD. He did not have clinically significant distress or impairment in social and occupational functioning due to psychiatric problems. No Axis I diagnosis was made. A VA neurological examination was also conducted in February 1998. The veteran reported that while playing football in 1968, he had collided with another player and had a loss of consciousness for three days. He indicated he was hospitalized on his base for two weeks. When he awoke, he had ringing in both ears, headaches and decreased hearing. He was informed that he had a concussion. The diagnosis was history of head injury and concussion in 1968; post- concussion headaches and a normal neurological examination. The report of a February 1998 VA joints examination has been associated with the claims file. The veteran reported that he had dislocated his left shoulder playing football in 1968. He again dislocated the shoulder in 1969, playing football. He reported that he had injured his right shoulder at the same time as the left shoulder. He related that he had dislocated his left elbow in 1969 while playing football. He was informed at that time that he had torn ligaments. He stated he injured his right knee in 1969 jumping off a truck. He re-injured the knee playing football and softball. He reported he injured his left ankle playing baseball in 1969. He was put on crutches for five weeks after the injury. X- rays revealed a fracture. X-rays of the left and right shoulders were interpreted as revealing minor degenerative joint disease of both shoulders and a bone infarct of the proximal humerus. X-rays of the left elbow were interpreted as revealing mild degenerative joint disease. X-rays of the right knee showed right tri- compartment degenerative joint disease involving the knee medial and patella femoral joint. X-rays of the left ankle revealed degenerative joint disease. The diagnoses from the examination were carpal tunnel syndrome of the left post neural linear release; minor degenerative joint disease of both shoulders; proximal left humerus shaft with bone infarct which was a residual of an old shoulder injury; minor degenerative joint disease of both elbows; tri-compartment degenerative joint disease involving the right knee and left ankle degenerative joint disease. On audiological evaluation in March 1998, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 30 50 85 90 LEFT 25 30 45 80 80 Speech audiometry revealed speech recognition ability of 98 percent in the right ear and of 94 percent in the left ear. The veteran complained of tinnitus and hearing loss, which he related to a head injury and excessive noise exposure during active duty. Criteria The threshold question that must be resolved is whether the veteran has presented evidence of well-grounded claims. See 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded claim is a plausible claim that is meritorious on its own or capable of substantiation. See Murphy, 1 Vet. App. at 81. If a claim is not well grounded there is no duty to assist the veteran with the development of that claim, and it must be denied. Morton v. West, 12 Vet. App. 477 (1999). An allegation of a disorder that is service connected is not sufficient; the veteran must submit evidence in support of a claim that would "justify a belief by a fair and impartial individual that the claim is plausible." See 38 U.S.C.A. § 5107(a); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The quality and quantity of the evidence required to meet this statutory burden of necessity will depend upon the issue presented by the claim. Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993). In determining whether a claim is well grounded, the claimant's evidentiary assertions are presumed true unless inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis); of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). In order to obtain service connection, there must be both evidence of a disease or injury that was incurred in or aggravated by service, and a present disability which is attributable to such disease or injury. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. A claim for service-connection for a disability must be accompanied by evidence which establishes that the claimant currently has the claimed disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); see also Brammer v. Derwinski, 3 .Vet. App. 223, 225 (1992) (absent proof of a present disability there can be no valid claim). Where the determinant issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Lay assertions of medical causation cannot constitute evidence to render a claim well grounded under 38 U.S.C.A. § 5107(a) (West 1991); if no cognizable evidence is submitted to support a claim, the claim cannot be well grounded. Id. The Court has held in Savage v. Gober, 10 Vet. App. 488 (1997), that the "continuity of symptomatology" provision of 38 C.F.R. § 3.303(b) may obviate the need for medical evidence of a nexus between present disability and service. See Savage, 10 Vet. App. at 497. The only proviso is that there be medical evidence on file demonstrating a relationship between the veteran's current disability and his post-service symptomatology, unless such a relationship is one as to which a lay person's observation is competent. Where a veteran served continuously for 90 days or more during a period of war and arthritis, psychosis or organic disease of the nervous system to include sensorineural hearing loss becomes manifest to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). When a disability is not initially manifested during service or within an applicable presumptive period, "direct" service connection may nevertheless be established by evidence demonstrating the disability was in fact incurred or aggravated during the veteran's service. See 38 U.S.C.A. § 1113(b) (West 1991 & Supp. 1999); 38 C.F.R. § 3.303(d). Hearing status will be considered a disability for the purpose of service connection when the auditory thresholds in any of the frequencies of 500, 1,000, 2,000, 3,000, and 4,000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (1999). The Court, in Hensley v. Brown, 5 Vet. App. 155 (1995), indicated that § 3.385 does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service. As stated by the Court, "[i]f evidence should sufficiently demonstrate a medical relationship between the veteran's in- service exposure to loud noise and his current disability, it would follow that the veteran incurred an injury in service; the requirements of § 1110 would be satisfied." Id. at 160 (citing Godfrey v. Derwinski, 2 Vet. App. 352 (1992)). Under the provisions for direct service connection for PTSD, 60 Fed. Reg. 32807-32808 (1999) (codified at 38 C.F.R. § 3.304(f)), service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (diagnosis of mental disorder); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to this combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See Moreau v. Brown, 9 Vet. App. 389, 394 (1996). The VA regulation was changed in June 1999 to conform to the Court's determination in Cohen v. Brown, 10 Vet. App. 128 (1997). As the Cohen determination was in effect when the RO last reviewed this case, the Board finds no prejudice to the veteran in proceeding with this case at this time. See Bernard v. Brown, 4 Vet. App. 384 (1993). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). I. Entitlement to Service Connection for Post-Traumatic Stress Disorder. Analysis A PTSD claim is well grounded if there is medical evidence of a current disability, lay evidence (presumed to be credible for these purposes) of an in-service stressor, which in a PTSD case is the equivalent of in-service incurrence or aggravation; and medical evidence of a nexus between service and the current PTSD. Gaines v. West, 11 Vet. App. 353, 357 (1998). Where there is a clear diagnosis of PTSD, an appellant's assertions of participation in combat are generally accepted as true for purposes of determining whether the claim is well grounded. Falk v. West, 12 Vet. App. 402, 404 (1999); but see Samuels v. West, 11 Vet. App. 11 Vet. App. 433 (1998) (VA is not required to accept the truthfulness of inherently incredible assertions). The Board finds that the veteran's claim of entitlement to service connection for PTSD is not well grounded. The veteran's claim is lacking a diagnosis of PTSD. There were no complaints of, diagnosis of or treatment for any mental disorders during the veteran's period of active duty. The February 1998 VA PTSD examination that was conducted specifically to determine if the veteran had PTSD did not result in a diagnosis of the disorder. No mental disorder was found. There are no diagnoses of PTSD included in the claims file. There is no competent evidence of record demonstrating a psychosis was present to a compensable degree within one year of discharge. The veteran alleges that he has PTSD as the result of his experiences during active duty. However, he has presented no competent medical evidence to support his allegation of having PTSD. A claim for service-connection for a disability must be accompanied by evidence, which establishes that the claimant currently has the claimed disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); see also Brammer v. Derwinski, 3 .Vet. App. 223, 225 (1992) (absent proof of a present disability there can be no valid claim). II. Entitlement to Service Connection for Bilateral Hearing Loss. Analysis The Board finds the veteran's claim of entitlement to service connection for bilateral hearing loss to be not well grounded. Review of the service medical records discloses that right ear hearing loss for VA purposes was present at the time of the veteran's entrance examination that was conducted in March 1968. However, hearing loss for VA purposes was not present at the time of the separation examination conducted in November 1970. Under the provisions of 38 U.S.C.A. § 1111, a veteran is presumed to be in sound condition at the time of entry onto active service, except for conditions noted at the time of his examination and acceptance for entry into service. This presumption is rebuttable by clear and unmistakable evidence to the contrary. Since the veteran's right ear hearing loss was noted at the time of the examination for entrance into service, the presumption of soundness is not for application. Under the provisions of 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306, service connection may still be granted for a pre- existing condition, provided that condition was aggravated during service. However, for such a claim to be well grounded there must be competent medical evidence that the disability was aggravated in service. Maxson v. West, 12 Vet. App. 453, 457 (1999). In the instant case, the veteran's right ear hearing loss at the time of separation from service had improved to the point that it would not constitute a disability as defined by VA. There is no other competent evidence that the hearing loss underwent an increase in service. He has testified that his hearing loss is the result of a head injury that occurred during active duty and to noise exposure as a result of operating heavy equipment during active duty. The Board notes the veteran's hearing actually improved from the time of his entrance examination to the time of his exit examination which was after the time of the alleged head injury. While the veteran is competent to report such a head injury, there is no competent evidence of record linking any current hearing loss to a head injury in service. There is also no competent evidence demonstrating the presence of hearing loss to a compensable degree within one year of discharge. The post-service evidence shows that the veteran has a current hearing loss in both ears as defined by VA. No competent evidence has been associated with the claims file demonstrating that the current bilateral hearing loss is related to active duty. The examiner who conducted the March 1998 audiological examination did not link the hearing loss to the veteran's period of active duty in any way. The Board notes the veteran's testimony indicating that he had hearing loss since active duty. The Board finds, however, while the veteran is competent to report a decrease in hearing since active duty, he is not competent to quantify the extent of the hearing loss as being sufficient hearing loss for VA purposes to be compensable or to attribute the hearing loss to an in-service head injury. No competent evidence of record has linked the veteran's reported hearing loss symptomatology to active duty. His testimony is not sufficient to well ground his claim. See Savage v. Gober, 10 Vet. App. 488 (1997). Additionally, the Board notes the veteran testified to exposure to loud noises subsequent to his discharge. There is no competent evidence of record showing the veteran currently has hearing loss as a result of active duty. The veteran's claim that he has hearing loss as a result of active duty is predicated upon his own unsubstantiated opinion. III. Entitlement to service connection for residuals of a right knee injury. Analysis The Board finds the claim of entitlement to service connection for residuals of a right knee injury to be not well grounded. The veteran was treated several times in September 1969 for a right knee sprain. However, on a subsequent examination conducted in July 1970, it was determined the veteran was fit to play football again. Residuals of a right knee injury were not found at the time of the November 1970 separation examination. In any event the service medical records, together with the veteran's statements, provide competent evidence of inservice incurrence of a right knee disability. The VA joints examination conducted in February 1998 resulted in a diagnosis of tri-comparment degenerative joint disease involving the right knee. Thus there is also competent evidence of a current disability. However, the disorder was not linked to active duty in any way. The veteran testified that he had difficulties with his right knee after separation from active duty. While the veteran is competent to provide evidence regarding post-service right knee symptomatology, he is not competent to attribute the symptomatology to any incident of active duty. No competent evidence of record has linked the veteran's current right knee symptomatology to active duty. See Savage v. Gober, 10 Vet. App. 488 (1997). In the absence of competent evidence of a nexus between the current right knee disability and service, the claim is not well grounded and must be denied. IV. Entitlement to Service Connection for Headaches Claimed as Residual of Head Injury. Analysis The Board finds the claim of entitlement to service connection for headaches as a residual of a head injury to be not well grounded. The veteran has testified he was hospitalized after a head injury for approximately two weeks at Fort Rucker during active duty. The only evidence of record of a head injury incurred during active duty is included on a document the veteran completed himself in February 1969. He indicated on the document he had been hospitalized in October 1968 for observation of a head injury as a result of playing football. However there were no complaints of, diagnosis of or treatment for headaches evidenced by the service medical records. Headaches were note reported on the separation examination. There is no clinical evidence in the service medical records showing the veteran experienced a concussion during active duty. No type of headache was noted at the time of the service exit examination and the veteran subsequently affirmed there had been no change in his condition at the actual time of separation. There is no evidence showing the service medical records are incomplete. The Board notes a single sheet of clinical records dated from June 1968 to February 1969 was included in the service medical records. The records, which span the time frame when the veteran alleged he was hospitalized, do not evidence such alleged hospitalization in any way. Additionally, the Board notes the veteran testified he was treated for headaches after his concussion during active duty. When asked if his headaches were attributed to a concussion at that time, the veteran testified that they were not because "they couldn't find... the deal in the medical records..." The examiner who conducted the VA neurological examination in February 1998 included diagnoses of history of head injury and concussion in 1968 and also post-concussion headaches. This diagnosis was based on a history reported by the veteran. While the veteran would be competent to report a history of head injury, he would not be competent to report the diagnosis of concussion. Thus the diagnosis of post- concussion headaches is of no probative value since it is based on an erroneous history. An assessment based on an inaccurate history supplied by the veteran is of no probative value. See Boggs v. West, 11 Vet. App. 334, 345 (1998); see also Kightly v. Brown, 6 Vet. App. 200, 205-06 (1994) (finding that presumption of credibility of evidence did not arise as to medical opinion that veteran's disability was incurred in service because it was based on an inaccurate history, one which failed to acknowledge an injury well- documented in record, and hence holding such evidence not "material"); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (finding that presumption of credibility did not arise because physician's opinion was based upon "an inaccurate factual premise" and thus had "no probative value" since it relied upon veteran's "account of his medical history and service background). The Board finds the veteran is competent to report as to headaches he experienced during and after active duty. He is not competent, however, to make a medical diagnosis that he had a concussion during active duty or to relate his headaches to such alleged concussion. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The service medical record evidencing hospitalization for observation of a head injury was not a clinical record but instead was the veteran's self-reported history. The veteran testified that even during active duty, medical records demonstrating the presence of a concussion could not be found. The post-service diagnoses of an in-service concussion and post-concussion headache were again based on the veteran's self reported history which is not supported by clinical evidence and therefor not probative. In this case there is no competent evidence of a nexus between any current headache disorder and a disease or injury in service. V. Entitlement to Service Connection for Tinnitus Claimed as Residual of Head Injury. Analysis The Board finds the claim of entitlement to service connection for tinnitus to be not well grounded. The veteran alleged his tinnitus was the result of a head injury he received playing football and to exposure to loud noises while operating heavy equipment during active duty. However, there were no complaints of, diagnosis of or treatment for tinnitus during active duty. Tinnitus was noted at the time of the March 1998 audiological evaluation. The disorder was not linked by the examiner to active duty in any way. The veteran has testified that his tinnitus began during active duty and had been present since that time. The Board finds the veteran is competent to report on the presence of tinnitus but is not competent to link the disorder to any incident of active duty. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The tinnitus symptomatology the veteran testified to was not linked to active duty in any way by competent evidence. See Savage v. Gober, 10 Vet. App. 488 (1997). As reported above, there is no clinical evidence of the veteran sustaining a head injury during active duty. While the veteran is competent to report such an injury, the Court has specifically held that there must be competent evidence linking a current diagnosis to the head injury, or to a continuity of symptomatology reported by the veteran. Kessel v. West, 13 Vet. 9 (1999). As there is no competent evidence of record linking current tinnitus to active duty, the claim must be denied as not well grounded. VI. Entitlement to Service Connection for Residuals of Bilateral Shoulder Injuries. Analysis The Board finds the claim of entitlement to service connection for residuals of bilateral shoulder injuries is not well grounded as there is no evidence of a current disability that has been linked to active duty. There were two complaints of shoulder problems in July 1969 during the veteran's period of active duty. The only assessment of the disorder was based on an X-ray of the right shoulder which was interpreted as possibly showing some widening of the acromioclavicular joint but such widening could only be seen by comparative weight bearing films which were not taken. The service medical records are silent as to complaints of shoulder problems for the remaining approximately one and one half years of the veteran's tour of duty. Nonetheless, this record combined with the veteran's report of shoulder injury in service, constitutes competent evidence of service incurrence. There is evidence of record of post-service shoulder disorders. Thus the requirement of a current disability has been satisfied. Degenerative changes were noted in the shoulder in August 1995 but the findings were not linked to active duty. The veteran complained, in pertinent part, of shoulder pain in October 1995. The diagnosis was left carpal tunnel syndrome. The 1998 VA examination resulted in pertinent diagnoses of minor degenerative joint disease of both shoulders and a proximal left humerus shaft with bone infarct that was a residual of an old shoulder injury. Neither of the diagnoses was linked to active duty. As there is no competent evidence of record demonstrating a nexus between a current shoulder disorder and service, the claim must be denied as not well grounded. VII. Entitlement to Service Connection for Residuals of a Left Ankle Injury. Analysis The veteran reported at the time of the February 1998 VA joints examination that he injured his left ankle playing baseball in 1969. He alleged he was put on crutches for five weeks after the injury and that X-rays revealed a fracture. The veteran is competent to report such an injury, and his statement constitutes competent evidence of inservice incurrence of an ankle injury (although he would not be competent to diagnose fracture). The pertinent diagnosis included on the February 1998 VA joints examination was left ankle degenerative joint disease. Thus there is competent evidence of a current disability. However, the disorder was not linked to active duty in any way, and the veteran would not be competent to express an opinion that his current disability was caused by the reported injury in service. As there is no competent evidence of record linking a currently existing left ankle disorder to active duty, the claim must be denied as not well grounded. VIII. Entitlement to Service Connection for a Left Elbow Injury. Analysis The service medical records show that the veteran sought treatment several times in August 1970 for an injury to the left elbow. X-rays taken at that time did not reveal a fracture. In December 1970, the veteran again sought treatment for a left elbow disorder. It was reported at that time that he developed synovitis. X-rays taken at that time failed to reveal any significant abnormalities. The diagnosis was contusion. These records provide competent evidence of inservice incurrence of a left elbow injury. Post-service, pain in the left elbow was reported in October 1995. The diagnosis was left carpal tunnel syndrome. The veteran reported at that time that the pain started approximately one year earlier. The February 1998 VA joints examination included a finding of left carpal tunnel syndrome status post neural linear release. These records provide competent evidence of a current disability. Significantly, none of the post-service evidence associated with the claims file has associated the left elbow disorder to active duty. As there is no competent evidence of record linking a current left elbow disorder to active duty or to a continuity of symptomatology, the claim of entitlement to service connection must be denied. The veteran testified he had had problems with his left elbow since active duty. This testimony constitutes competent evidence of a continuity of symptomatology. However, no competent evidence of record has linked the allegations of continuous left elbow symptomatology to active duty in any way. See Savage v. Gober, 10 Vet. App. 488 (1997). IX. Entitlement to Service Connection for Residuals of a Low Back Injury. Analysis The first clinical evidence of a back disorder was 1995 X- rays from the Austin Diagnostic Clinic which revealed developmental variation in the lower endplates of C6 and C7 as well as in the lumbar vertebral bodies. Private treatment records also dated in 1995 include complaints of back pain. There is no indication in the clinical records that the back pain was of long standing duration. In fact, it was noted on one clinical record that the back pain began approximately one year prior to the treatment. The back pain was not linked to active duty in any way. Chronic back pain, back injury in 1970, as well as minimal early degenerative joint disease at L4-5 were included as separate diagnosis on the report of the February 1998 spine examination. The Board notes, however, that the examiner did not relate any of these diagnoses to each other. The diagnosis of a back injury in 1970 is based on the veteran's own self-reported history and not supported by clinical evidence. Medical evidence that relies on history provided by the veteran is not probative. The Court has made clear that medical opinions based on a history furnished by the veteran and unsupported by the clinical evidence are of low or limited probative value. Curry v. Brown, 7 Vet. App. 59, 68 (1994). The veteran testified he was treated for a back injury shortly after his discharge from active duty. He further testified he would obtain those treatment records. He has not done so nor has he requested VA to obtain the records. As there is no competent evidence of record linking a current back disorder to active duty, the claim of entitlement to service connection for residuals of a low back injury must be denied as not well-grounded. As it is the province of trained health care professionals to enter conclusions which require medical opinions as to causation, Grivois v. Brown, 6 Vet. App. 136 (1994), the veteran's lay opinions are an insufficient basis upon which to find these claims well grounded. Espiritu v. Derwinski, 2 Vet. App. 492 (1992); King v. Brown, 5 Vet. App. 19, 21 (1993). The Board finds that the RO has advised the veteran of the evidence necessary to establish well grounded claims, and the veteran has not indicated the existence of any post service medical evidence that has not already been obtained that would well ground his claims. McKnight v. Gober, 131 F.3d 1483 (Fed.Cir. 1997); Epps v. Gober, 126 F.3d 464 (Fed.Cir. 1997). The Board notes the veteran's testimony as to treatment he received from Dr. R. who is his family physician. He also testified to the fact that he received treatment from an outpatient clinic and other facilities in Austin, Texas. These records have not been associated with the claims file. The Board further notes, the veteran testified at the august 1997 RO hearing that he would obtain all these outstanding treatment records or would sign releases for VA to obtain them. He did not do so. The Board reminds the veteran if he wants VA to consider documents not in the possession of the Federal Government, he must either (1) furnish them to VA, or (2) request VA to obtain them by providing an appropriate release for such purpose, and by demonstrating how the documents are relevant to his claim. Counts v. Brown, 6 Vet. App. 473, 479 (1994). As such, additional development in this regard is not warranted. As the veteran's claims for service connection for post- traumatic stress disorder, bilateral hearing loss, residuals of a right knee injury, headaches claimed as residual of head injury, tinnitus claimed as residual of head injury, residuals of bilateral shoulder injuries, residuals of a left ankle injury, a left elbow injury and for residuals of a low back injury are not well grounded, the doctrine of reasonable doubt is not applicable to his case. ORDER The veteran not having submitted well-grounded claims of entitlement to service connection for post-traumatic stress disorder, bilateral hearing loss, residuals of a right knee injury, headaches claimed as residual of head injury, tinnitus claimed as residual of head injury, residuals of bilateral shoulder injuries, residuals of a left ankle injury, a left elbow injury and for residuals of a low back injury, the claims are denied. REMAND The veteran has expressed disagreement with the denial of service connection for a right elbow disability. Because a notice of disagreement was filed with the decision, and no statement of the case has been issued, case must be remanded to the RO for the issuance of a statement of the case. 38 U.S.C.A. § 7105; Tablazon v. Brown, 8 Vet. App. 359, 361 (1995). Therefore, the case is remanded for the following action: The RO should issue a statement of the case as to the issue of entitlement to service connection for a right elbow disability. The veteran and representative, if any, should be given the opportunity to respond thereto. Only if the veteran files a timely substantive appeal should the veteran's claim be returned to the Board. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Veterans Appeals for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1998) (Historical and Statutory Notes). In addition, VBA's ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. Mark D. Hindin Member, Board of Veterans' Appeals