Citation Nr: 0803125 Decision Date: 01/29/08 Archive Date: 02/08/08 DOCKET NO. 04-31 670 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for patellofemoral pain syndrome, right knee. 2. Entitlement to an initial evaluation in excess of 10 percent for patellofemoral pain syndrome, left knee. 3. Whether new and material evidence has been received sufficient to reopen a previously denied claim of entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for tinnitus, to include as secondary to bilateral hearing loss. 5. Entitlement to service connection for post-traumatic stress disorder (PTSD), (6) a low back disability, (7) residuals of a left side trunk injury, (8) sinusitis, (9) headaches, (10) left foot disability, (11) right ankle disability, (12) left ankle disability, (13) bilateral ear disorder. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARINGS ON APPEAL The veteran and her friend ATTORNEY FOR THE BOARD N. Kroes, Associate Counsel INTRODUCTION The veteran served on active duty from January 1981 to January 1988. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Waco, Texas, Department of Veterans Affairs (VA) Regional Office (RO). In January 2005, the veteran testified at a personal hearing before a Decision Review Officer at the RO. In October 2007, the veteran testified at a personal hearing before the undersigned Veterans Law Judge at the RO. Transcripts of those hearings have been associated with the claims file. The veteran submitted additional evidence at the October 2007 hearing and waived initial consideration of the evidence by the RO. See 38 C.F.R. § 20.1304(c) (2007). The issues of entitlement to service connection for sinusitis and low back disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Patellofemoral pain syndrome, left and right knee, is currently primarily manifested by pain, tenderness, limitation of flexion to 110 degrees or greater and occasional swelling and stiffness. Ankylosis, frequent episodes of "locking" and effusion into the joint, impairment of the tibia and fibula, genu recurvatum, recurrent subluxation, and lateral instability are not shown. 2. Service connection for bilateral hearing loss was denied in a March 2005 rating decision. The veteran was notified of this decision and of her appeal rights at that time and did not appeal the decision. It was held that there was no current diagnosis of bilateral hearing loss, and that there was no evidence of treatment or diagnosis of this condition in service. The March 2005 rating decision is final. 3. The evidence added to the record since the last final denial of entitlement to service connection for bilateral hearing loss is cumulative and redundant and does not raise a reasonable possibility of substantiating the veteran's claim for service connection. 4. There is competent evidence of a diagnosis of post- traumatic stress disorder, which has been attributed to an in-service stressor. 5. There is credible, supporting evidence that the claimed in-service stressor occurred. 6. There is no competent medical evidence of current residuals of left side trunk injury, tinnitus, bilateral ear disorder, left ankle disability, and right ankle disability. 7. A chronic left foot disability was not present in service or for many years afterward, and is not etiologically related to service. 8. Chronic headaches were not present in service or for many years afterward, and are not etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 10 percent for patellofemoral pain syndrome, right knee, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.40, 4.45, 4.71a, DCs, 5003, 5258, 5260, 5261 (2007). 2. The criteria for an initial evaluation in excess of 10 percent for patellofemoral pain syndrome, left knee, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.40, 4.45, 4.71a, DCs, 5003, 5258, 5260, 5261 (2007). 3. A March 2005 rating decision denying the veteran's claim for entitlement to service connection for bilateral hearing loss is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.201, 20.302 (2007). 4. New and material evidence to reopen the veteran's claim for entitlement to service connection for bilateral hearing loss has not been received since the last final denial. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2007). 5. With resolution of reasonable doubt in the veteran's favor, post-traumatic stress disorder was incurred in service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2007). 6. Residuals of a left side trunk injury were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 3.303 (2007); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 7. Tinnitus was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 3.303 (2007); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 8. Bilateral ear disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 3.303 (2007); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 9. Left ankle disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 3.303 (2007); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 10. Right ankle disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 3.303 (2007); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 11. Left foot disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.303 (2007). 12. Headaches were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.303 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Kent v. Nicholson, 20 Vet. App. 1 (2006), the U.S. Court of Appeals for Veterans Claims (Court) clarified VA's duty to notify in the context of claims to reopen. With respect to such claims, VA must both notify a claimant of the evidence and information that is necessary to reopen the claim and notify the claimant of the evidence and information that is necessary to establish entitlement to the underlying claim for the benefit that is being sought. To satisfy this requirement, the Secretary is required to look at the bases for the denial in the prior decision and to provide the claimant with a notice letter that describes what evidence would be necessary to substantiate those elements required to establish service connection that were found insufficient in the previous denial. As the Board is remanding the claims for service connection for low back disability and sinusitis further discussion regarding compliance with the VCAA for these issues is unnecessary at this point. In this decision, the Board is granting the veteran's claim for entitlement to service connection for PTSD. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. Regarding the veteran's claim for an increased rating for bilateral knee disabilities, the VCAA duty to notify was satisfied by way of a letter sent to her in November 2002 that fully addressed all four notice elements and was sent prior to the initial AOJ decision in this matter. The letter informed the veteran of what evidence was required to substantiate the claim and of her and VA's respective duties for obtaining evidence. The veteran was also asked to submit evidence and/or information in her possession to the AOJ. In June 2006 the veteran was sent a VCAA notification letter regarding her claims for bilateral hearing loss, tinnitus, bilateral ear condition, headaches, left foot disability, left and right ankle disabilities, and residuals of a left side trunk injury. This letter fully addressed all four notice elements and was sent prior to the initial AOJ decision in this matter. The letter informed the veteran of what evidence was required to substantiate the claims and of her and VA's respective duties for obtaining evidence. The veteran was given the definition of new and material evidence and told that her claim for service connection for bilateral hearing loss was previously denied because the evidence of record did not show that this condition had been clinically diagnosed, and a review of the service treatment records showed no treatment or diagnosis of hearing loss during military service. The veteran was also asked to submit evidence and/or information in her possession to the AOJ. During the pendency of this appeal, on March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The above notification letters did not include notice as to the last two elements; however, the Board finds no prejudice to the veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the veteran has been prejudiced thereby). As the Board concludes below that the preponderance of the evidence is against the veteran's claim to reopen and claims for service connection, any questions as to the appropriate disability ratings or effective dates to be assigned are rendered moot. Regarding the veteran's claim for an increased rating, she is appealing the degree of disability showing actual knowledge of that element. As there will be no further increase as a result of this decision, further information about effective dates is not needed. Furthermore, the veteran was given notice as to degrees of disability and effective dates in a March 2006 letter, issued the same month the Court decided Dingess/Hartman. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has of record private medical records, VA treatment records, Vet Center treatment records, "buddy" letters, articles about sexual assaults in the military, hearing transcripts, service personnel records, and service treatment records. There is no indication that any other treatment records exist that should be requested, or that any pertinent evidence has not been received. A VA examination was provided in connection with the increased rating claims, and the service connection claims relating to the veteran's ears and hearing. The veteran was not afforded a VA examination in connection with her claims for service connection for headaches, left side trunk disability, left foot disability, and bilateral ankle disability. The Board is of the opinion that there is sufficient competent medical evidence of record to make decisions on all of these claims. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, examinations are not needed for the veteran's claims for service connection for left foot disability and headaches as there is no indication that either of these disabilities may be associated with the veteran's active military service. The veteran's discharge examination shows a normal clinical evaluation of the feet and a normal neurological evaluation. At that time the veteran denied foot trouble and frequent or severe headaches. The current left foot problems (pain and plantar fasciitis) do not appear on the face to be in any way related to the veteran's in- service complaints (numbness). The veteran's current complaints of headaches have been explained as related to smelling perfume and taking medication, and her in-service complaints were attributed to rhinosinusitis and an incorrect eye glass prescription. The first showing of left foot disability and headaches are both years after her service. None of the competent medical evidence of record suggests that the veteran's current left foot disability and headaches are related to her service. Likewise, as explained below, the evidence of record does not show a continuity of symptomatology for either of these disabilities. Thus, the Board finds that VA examinations are not necessary for these disabilities. See id.; see also 38 U.S.C.A. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). As discussed below, there is no competent evidence of current residuals of left side trunk injury, left ankle disability, and right ankle disability, or persistent or recurrent symptoms of any of these disabilities. While the veteran has reported some symptomatology related to these disabilities, such as ankle pain, persistent or recurrent symptoms of these disabilities are not shown by the evidence of record. See id. Accordingly, the Board finds that VA examinations are not necessary for these disabilities. See id. For the foregoing reasons, the Board therefore finds that VA has satisfied its duty to notify (each of the four content requirements) and the duty to assist pursuant to the VCAA. See 38 U.S.C.A. §§ 5102 and 5103 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.159(b), 20.1102 (2007); Pelegrini, supra; Quartuccio, supra; Dingess, supra. Any error in the sequence of events or content of the notice is not shown to have any effect on the case or to cause injury to the claimant. Thus, any such error is harmless and does not prohibit consideration of this matter on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Increased Rating for Both Knees The veteran contends that left and right knee patellofemoral pain syndrome is worse than currently evaluated. Applicable Law Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, as here, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2 (2007). The Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, No. 05-2424 (U.S. Vet. App. Nov. 19, 2007). The analyses in the following decision are therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Included within 38 C.F.R. § 4.71a are multiple diagnostic codes that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). According to DC 5257, which rates impairment resulting from other impairment of the knee, to include recurrent subluxation or lateral instability of this joint, a 10 percent rating will be assigned with evidence of slight recurrent subluxation or lateral instability of a knee; a 20 percent rating will be assigned with evidence of moderate recurrent subluxation or lateral instability; and a 30 percent rating will be assigned with evidence of severe recurrent subluxation or lateral instability. See 38 C.F.R. § 4.71a, DC 5257. Pursuant to 38 C.F.R. §§ 4.40 and 4.45, pain is inapplicable to ratings under DC 5257 because it is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). The words "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6 (2007). Dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent evaluation. See 38 C.F.R. § 4.71a, DC 5258. Traumatic arthritis is rated analogous to degenerative arthritis under DC 5003. See 38 C.F.R. § 4.71a, DCs 5003, 5010 (2007). Degenerative arthritis, when established by x- ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. For purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). The diagnostic codes that focus on limitation of motion of the knee are DCs 5260 and 5261. Normal range of motion of the knee is from zero degrees extension to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. See 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, a noncompensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The VA Office of General Counsel has stated that compensating a claimant for separate functional impairment under DCs 5257 and 5003 does not constitute pyramiding. VAOPGCPREC 23-97 (July 1, 1997). In this opinion, the VA General Counsel held that a veteran who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257, provided that a separate rating is based upon additional disability. Subsequently, in VAOPGCPREC 9-98 (August 14, 1998), the VA General Counsel further explained that if a veteran has a disability rating under DC 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. See also VAOPGCPREC 9-04 (September 17, 2004) (which finds that separate ratings under DC 5260 for limitation of flexion of the leg and DC 5261 for limitation of extension of the leg may be assigned for disability of the same joint). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran 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). Facts & Analysis After a careful review of the evidence, the Board finds that the preponderance of such evidence is against a finding that the veteran warrants higher evaluations for her left and right knee disabilities. At the veteran's October 2007 personal hearing, she testified that her knees are painful and get stiff if she sits for any length of time. She also stated that her knees lock up at times, and that her physician at the VA diagnosed her with arthritis of the knees. In a September 2004 statement she states that she has knee pain, that her knees occasionally give out and that they swell up. The veteran was afforded a VA examination in August 2003. At that examination, the veteran complained of having knee pain, but no locking. She reported that stiffness is present in both knees which lasts until about noon, and that swelling occurs at a frequency of 2 times per week in bilateral knees. The examiner stated that there were no episodes of dislocation or recurrent subluxation. Bilateral knee range of motion was reported as 0 to 120 degrees, with pain at 120 degrees in the left knee more than the right. The examiner noted that repetitive use causes additional limitation of pain, mostly in the left knee, and no fatigue, weakness, or lack of endurance. X-rays from November 2002 were reported as normal. The diagnosis given was bilateral knee patellofemoral pain syndrome. A February 2003 VA outpatient treatment report shows an assessment of bilateral knee pain that was "likely djd." The Board notes that "djd" or "DJD" is a common medical acronym used to represent "degenerative joint disease." On examination there was good range of motion, a negative drawer sign and crepitus bilaterally, and no effusions or tenderness bilaterally. April 2003 knee x-rays were reported as normal. A July 2003 VA physical therapy consultation report shows that the veteran's active knee range of motion was within normal limits at that time, and that varus valgus stress tests and drawer signs were negative as well. VA treatment records from 2004 show tenderness, but no effusion. A September 2005 VA treatment note shows a subjective complaint of "DJD - Knees hurt." One of the listed assessments is DJD. The veteran was afforded a second VA examination in November 2006. At that examination, the veteran complained of having knee pain, stiffness, swelling and popping, but no locking, giving out, or falling. When asked to describe any episodes of dislocation or recurrent subluxation, the examiner replied that the question was nonapplicable. On physical examination, after repetition of range of motion the left knee had an increase in pain and fatigue, and the right knee had popping and an increase in pain. Neither knee had a change in the range of motion or other limitation. The examiner did note crepitus and slight swelling. Ranges of motion were reported as right knee 0 to 110 degrees active range of motion and 0 to 120 passive with pain, and left knee 0 to 140 without pain. Extension was reported as full bilaterally, and stability was reported as normal. X-rays reportedly failed to reveal any fracture, dislocation, or any other bone and joint abnormalities, and the impression given was that it was a negative study. The examiner's diagnosis was bilateral patellofemoral pain syndrome with anserine bursitis. As tibia and fibula impairment, genu recurvatum, and ankylosis related to either knee is not shown by the competent medical evidence, a higher rating is not warranted for left or right knee patellofemoral pain syndrome under DCs 5256, 5262, and 5263. See 38 C.F.R. § 4.71a, DCs 5256, 5262, 5263. While pain is certainly an element of the veteran's left and right knee patellofemoral pain syndrome, the veteran has on at least one occasion denied episodes of either knee "locking"(she did report at her October 2007 hearing that her knee locks up), and the competent evidence repeatedly shows no effusions related to either disability. As such, the Board finds that the preponderance of the competent medical evidence is against a finding that the veteran has dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusions into the joint. See 38 C.F.R. § 4.71a, DC 5258. While some treatment reports list assessments of degenerative joint disease, also known as arthritis, this condition has not been shown by x-ray evidence as is required for a rating under DC 5003. See 38 C.F.R. § 4.71a DC 5003. Lateral instability and recurrent subluxation are not shown by the competent medical evidence. At the veteran's August 2003 VA examination the examiner stated that there were no episodes of dislocation or recurrent subluxation, and at the veteran's November 2006 VA examination stability was reported as normal. The other competent medical evidence does not show recurrent subluxation or lateral instability either; in fact, a July 2003 VA physical therapy consultation report shows that varus valgus stress tests and drawer signs were negative at that time. Considering any loss of range of motion, the competent medical evidence does not show flexion of either knee limited to 20 degrees or extension of either knee to 15 degrees as would be required for evaluations in excess of 10 percent. See 38 C.F.R. § 4.71a, DCs 5260, 5261. According to the August 2003 VA examiner, bilateral knee range of motion was reported as 0 to 120 degrees with pain at 120 degrees. According to the November 2006 VA examiner, extension was full in both knees, the right knee had flexion to 110 degrees (active range of motion), and the left knee had flexion to 140 degrees. As such, initial evaluations in excess of 10 percent based on loss of range of motion are not warranted. See id. The Board has considered the applicability of DeLuca v. Brown, 8 Vet. App. 202, including whether there is a basis for assigning a rating in excess of 10 percent for either left or right knee patellofemoral pain syndrome due to additional limitation of motion resulting from pain or functional loss. See 38 C.F.R. §§ 4.40 and 4.45. There is no question in this case that pain is a component of the veteran's disabilities. Nevertheless, the Board finds that the effects of pain reasonably shown to be due to the veteran's service-connected bilateral knee disabilities are contemplated in the 10 percent ratings currently assigned. There is no indication that pain, weakness, fatigability, and incoordination caused functional loss greater than that contemplated by the 10 percent evaluations assigned by the RO. See 38 C.F.R. § 4.40; DeLuca, supra. In fact, while the February 2006 VA examiner noted that after repetition of range of motion the left knee had an increase in pain and fatigue, and the right knee had popping and an increase in pain, the examiner also specifically stated that neither knee had a change in the range of motion or other limitation. Conclusion The veteran is competent to report her symptoms. To the extent that the veteran has asserted that she warrants more than a 10 percent evaluation for either knee disability the Board finds that the preponderance of the evidence does not support her contentions, for all the reasons stated above. The Board is responsible for weighing all of the evidence and finds that the preponderance of it is against initial evaluations in excess of 10 percent for left and right knee patellofemoral pain syndrome, and there is no doubt to be resolved. Gilbert, 1 Vet. App. at 55. The Board finds no basis upon which to predicate assignment of "staged" ratings. The Board notes it does not find that consideration of extraschedular ratings under the provisions of 38 C.F.R. § 3.321(b)(1) (2007) is in order. The Schedule for Rating Disabilities will be used for evaluating the degree of disabilities in claims for disability compensation. The provisions contained in the rating schedule will represent as far as can practicably be determined, the average impairment in earning capacity in civil occupations resulting from disability. Id. In the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability. The governing norm in these exceptional cases is: a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. Id. The Board emphasizes that the percentage ratings under the Schedule are representative of the average impairment in earning capacity resulting from diseases and injuries. 38 C.F.R. § 4.1, states that "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." Thus, with this in mind, the Board finds that the veteran's symptoms that warrant the 10 percent evaluations for left and right knee patellofemoral pain syndrome are clearly contemplated in the Schedule and that the veteran's service- connected disabilities are not so exceptional nor unusual such as to preclude the use of the regular rating criteria. III. New and Material Evidence The Board, in the first instance, must rule on the matter of reopening a claim. The Board has a jurisdictional responsibility to consider whether it is proper for a claim to be reopened. Jackson v. Principi, 265 F.3d 1366 at 1369 (Fed. Cir. 2001) and Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). When determining whether the veteran has submitted new and material evidence to reopen a claim, consideration must be given to all the evidence since the last final denial of the claim. Evans v. Brown, 9 Vet. App. 273 (1996). In Evans, the Court indicated that the newly presented evidence need not be probative of all the elements required to award the claim, but need only tend to prove each element that was a specified basis for the last disallowance. Id. at 284. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2007). Service connection for a "chronic disease," such as sensorineural hearing loss, may be granted if manifest to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.307, 3.309 (2007). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The veteran contends that she has bilateral hearing loss disability as a result of her active military service. Service connection for bilateral hearing loss was denied in a March 2005 rating decision. The veteran was notified of this decision and of her appeal rights at that time and did not appeal the decision. It was held that there was no current diagnosis of bilateral hearing loss, and that there was no evidence of treatment or diagnosis of this condition in service. The March 2005 rating decision is final. See 38 U.S.C.A. § 7105; 38 C.F.R. §§ 20.201, 20.302. The Board has reviewed the evidence received since the last final denial and finds that none of it is new and material evidence. The only evidence received since the March 2005 rating decision relevant to bilateral hearing loss is statements and testimony from the veteran. At her October 2007 hearing she testified that while in service she had to operate loud sirens and qualify with different types of firearms, and that she did not always wear hearing protection. She further testified that she now has trouble comprehending what people say to her, especially if there is any kind of background noise. Such argument had been made at the time of the last final denial and thus it is cumulative and redundant of the evidence that was of record at the time of the last final denial. Reid v. Derwinski, 2 Vet. App. 312 (1992). Regardless of the duplicative nature of the current assertions, these statements would not be competent to reopen the claim for service connection for bilateral hearing loss, as that requires a medical opinion. See Moray v. Brown, 5 Vet. App. 211 (1993) (lay assertions on medical causation do not constitute material evidence to reopen a previously denied claim). The Board is aware that a service treatment record from August 1985 shows that at that time the veteran complained of difficulty understanding what people said in noisy areas. The assessment at that time noted that hearing in both ears was well within normal limits. This evidence was considered at the time of the initial denial. While some of this evidence is new as it was not previously on file, it is not material. This is all cumulative and redundant of the evidence of record at the time of the last final denial and cannot constitute new and material evidence. See 38 C.F.R. § 3.156(a). None of the evidence received since the last final denial cures the defect of the lack of competent evidence of a current bilateral hearing loss disability, or evidence of treatment or diagnosis of this condition in service. Thus, the evidence received cannot constitute new and material evidence. See Cox v. Brown, 5 Vet. App. 95, 99 (1993). Therefore, based upon the above reasons, the Board finds that the evidence associated with the claims file since the last final denial is cumulative and redundant of evidence of record at the time of the last final denial and does not raise a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156(a). Accordingly, the application to reopen such claim is denied. IV. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To prevail on the issue of service connection, there must be medical evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The chronicity provision of 38 C.F.R. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. Savage v. Gober, 10 Vet. App. 488, 498 (1997). In addition, if a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. 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, 1 Vet. App. 49. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 3.102. After a careful review of the evidence, the Board finds that the preponderance of such evidence is against a finding that service connection is warranted for residuals of a left side trunk injury, bilateral ear disorder, left ankle disability, right ankle disability, left foot disability, headaches, and tinnitus, to include tinnitus as secondary to bilateral hearing loss. The Board finds that with reasonable doubt resolved in favor of the veteran service connection for PTSD is warranted. A. PTSD Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); 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. 38 C.F.R. § 3.304(f). The evidence necessary to establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD will vary depending upon whether the veteran engaged in "combat with the enemy." If the veteran engaged in combat with the enemy and her alleged stressor is combat- related, then her lay testimony or statement is accepted as conclusive evidence of the stressor's occurrence, and no further development or corroborative evidence is required - provided that such testimony is found to be "satisfactory," i.e., credible and "consistent with circumstances, conditions or hardships of service." See 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(f)(1); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). If, however, the alleged stressor is not combat related, then the claimant's lay statements, in and of itself, is not sufficient to establish the occurrence of the alleged stressor. See Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Instead, the record must contain evidence that corroborates the statements. See Cohen v. Brown, 10 Vet. App. 128, 147 (1997); Moreau v. Brown, 9 Vet. App. 389, 395 (1996); see also Zarycki, 6 Vet. App. at 98, Doran v. Brown, 6 Vet. App. 283, 289-290 (1994). At the veteran's October 2007 personal hearing, she testified that while in service she was sexually assaulted by her military police (MP) partner around 1985. She explained that she did not report this because prior to this incident she had witnessed two soldiers who were not prosecuted for rape after she and her MP partner witnessed them making exclamatory statements about raping a woman. The veteran gave similar testimony at her January 2005 personal hearing as well. At that hearing she also stated that she did not have a drinking problem prior to the rape incident. The veteran's friend testified that she has observed the veteran having the same symptoms as a retired police officer she knows who suffers from PTSD. In a June 2003 letter, the veteran details her in-service stressors. First, she states that she met some foreign soldiers and began playing a drinking game, and the next thing she knew she was in bed with a guy. She believes that she was drugged. Second, after coming back to base AWOL (absent without leave) for the second time, her sergeant told her that if it happened again she would owe him a "blow job." Third, she states that she was investigated for being a homosexual. Fourth, she states that she was invited along with fellow soldiers from the narcotics drug suppression team she was serving on to watch pornography and get drunk. The other soldiers reportedly did this frequently. The veteran decided to join them on one occasion. She states that she remembers being drunk and the next thing she knew her MP partner was having sex with her. She reports being in and out of consciousness and thinks that she may have been drugged. She cannot remember how she left the party or got home, but she did explain that she did not want to have sex with her partner. In this letter, the veteran also reports an incident where two soldiers made seemingly inculpatory statement about raping a woman to her and her MP partner (while they were working undercover as MP officers), and that later the rape charges were dropped. She further relayed that she was harassed and undermined by her First Sergeant. For example, he would call her and tell her he needed to see her and then when she arrived he would not see her until the end of the day when he would deny ever calling her. In an October 2007 letter the veteran explains that she was afraid to tell anyone that her MP partner had raped her because she had seen first hand what happened to MP officers who "ratted out" their partners, and because she had dealt with rape victims who were not believed. The veteran also explained that she turned to drugs and alcohol to help her cope with what had happened to her, and when she got clean she turned to food. The veteran's service personnel record shows that she was a member of the drug suppression team from July 1984 to August 1985. Her discharge examination in October 1987 shows that a psychiatric examination was not conducted at that time. The veteran's service records show a significant weight gain from 1983 to 1987 and also that the veteran was prescribed Antabuse, a drug used to treat chronic alcoholism, in 1986. A March 1980 enlistment examination reports her weight as 150, a February 1983 Airborne examination reports her weight as 154, and her October 1987 discharge examination reports her weight as 182. The veteran's October 1987 examination shows that compared to her February 1983 examination she had 3 additional tattoos. An August 1986 treatment note indicates that the veteran was taking Antabuse at that time. A Vet Center intake form, which reportedly was completed by staff with the client, states that the veteran's drug and alcohol use began at age 16, and that while in the Army her use became abuse especially after being raped. The veteran reported being raped by another MP officer with whom she worked. She also reported being harassed because she was a woman and being labeled as a lesbian. A multiaxial assessment was given and for Axis I, which the Board associates with identifying any clinical disorders or other conditions that may be a focus of clinical attention, the counselor (Ms. "D.E.," PhD, APRN, BC, LMFT) entered a diagnosis of Posttraumatic Stress Disorder, Chronic. Doctor "D.E." has submitted several letters to VA on behalf of the veteran. A July 2003 letter shows Axis I diagnoses of PTSD, chronic, and dysthymic disorder. Doctor "D.E." notes the veteran's history and current symptoms and then states that in her professional opinion the veteran's PTSD was triggered by the tremendous stresses and life threatening events that she experienced while serving in the Army. A December 2004 letter adds that after a review of the veteran's military records Dr. "D.E." has noted markers that support the veteran's claim of military sexual trauma. She states that the veteran went home on leave in the summer of 1985 and stayed drunk the entire time and wrote bad checks to pay for her drinking, which time she asserts would have been shortly after the rape. She notes that the service medical records show the veteran made a "request" for Antabuse in August of 1986. She also points out that in 1987 the veteran did not meet the height and weight standards required by the Army, and that when this happened in the 1983 the veteran lost the necessary weight to remain in compliance. However, after the 1987 episode of exceeding the standards, the veteran was no able to regain compliance and she continues to have weight management problems to this day. She notes that problems with weight control and obesity are commonly observed in survivors of sexual trauma and that both the veteran's weight and drinking problems are indicative of the severe stress she was coping with following her rape. Doctor "D.E." also points out that the veteran's mental health was not evaluated prior to her leaving service. Based on the above, Dr. "D.E." stated that in her professional opinion, it is more likely than not that the veteran's developed PTSD secondary to her military sexual trauma. Doctor "D.E." submitted similar letters in August 2006 and October 2007. The August 2006 letter emphasized that she believed that the veteran had been raped while in service, and that her symptoms and presentations (weight gain, heavy drinking, etc.) certainly pointed to sexual trauma in the military. An August 2005 letter submitted by the veteran's VA psychiatrist clarified that the veteran was being treated at VA for bipolar disorder and PTSD since September 2003. The letter was written to verify that these were both ongoing primary Axis I diagnoses. A letter received in July 2003 from a soldier who served in Germany around the same time as the veteran states that the soldier saw the veteran being picked on and treated with disrespect by her First Sergeant. Also in July 2003, the veteran's Narcotics Anonymous sponsor (since approximately 1994) submitted a letter stating that the veteran had shared with her the experiences of sexual abuse and sexual harassment that occurred while she was in the Army. A letter from the veteran's employer explains the on the job problems she currently experiences. The veteran submitted letters in April 2003 from her sister, friend, father, and partner. The veteran's sister states that while in the Army the veteran drank a lot, gained weight, and was aggressive. She states that this was a change in her sister and that she watched her sister go from being excited about serving her country to being unhappy and not being able to do the things she loves to do. The veteran's father reported that his daughter became distant while in service and that she drank heavily, seemed angry, bounced checks, and gained weight. He also stated that after her service he has witnessed her on numerous occasions to have sudden outbursts of anger and severe road rage. In closing he writes that he does not know exactly what happened to his daughter while in the service but he does know that she is not the same person she was when she joined the service. In a detailed letter the veteran's partner explains the veteran's current symptoms she has observed such as anger, frustration, fear, emotional numbness, hypervigilance, startling easily, paranoia, depression, overeating, and feelings of distress. She sent a similar letter in December 2004. According to a September 2006 letter from the veteran's best friend of 30 years, she noticed a change in the veteran's personality around 1985. She states that the veteran started drinking heavily, cursing, and that the veteran sounded very angry. Additionally, she got more tattoos, put on weight, and became very reckless and nonchalant about her health and safety. She relayed one incident in late 1985 where she and the veteran went out on the town while the veteran was home on leave. She writes that after much persuasion the veteran confided in her that her MP partner had sexually assaulted her. At the veteran's personal hearing in October 2007, the veteran stated that she did not remember telling her friend this, but that she had drunk until she blacked out that night. The veteran has submitted competent medical evidence showing a diagnosis of PTSD, and a link between this diagnosis and one of her claimed in-service stressors, specifically, being raped while in service. Accordingly, the only other thing needed for a grant of service-connection is credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). The veteran's service records show treatment for chronic alcoholism (1986) and significant weight gain (sometime after 1983). By the veteran's account, she was raped in 1985. She has also submitted numerous letters from friends and family alike detailing the changes they saw in her during service. Resolving reasonable doubt in the veteran's favor, the Board finds that the above evidence, when considered with the veteran's testimony and statements, is credible supporting evidence of the veteran's claimed stressor. As such, the Board finds that resolving reasonable doubt in the veteran's favor, service connection is warranted for PTSD. Gilbert, 1 Vet. App. 49. B. Residuals of a left side trunk injury, tinnitus, bilateral ear disability, and left and right ankle disabilities The veteran asserts that she currently has residuals of a left side trunk injury, tinnitus, bilateral ear disorder, and left and right ankle disabilities as a result of her active military service in the United States Army. At her October 2007 personal hearing, the veteran testified that she completed 15 to 20 parachute jumps while in service. She also relayed that as a military policewoman, she carried a lot of equipment such as a handgun, flashlight, baton, ammunition, and handcuffs. She stated that she first received treatment for her back after service after she was in a motorcycle accident. She relayed that she did not seek treatment for her back or trunk prior to the motorcycle accident because she could not afford to get treatment. She also testified that during service she had to operate loud sirens and qualify with different types of weapons and that she did not always wear hearing protection. She reportedly fell and punctured her eardrum while serving in Germany. Regarding any disability of the ankles, she testified that her ankles twist and give out frequently. She stated that she was not currently receiving treatment for this, besides ice and aspirin, because she would have to take time off work for treatment. She further contends that she may have tinnitus as a result of bilateral hearing loss. Initially, the Board points out that the veteran does not have service connection in effect for bilateral hearing loss and service connection for bilateral hearing loss is not awarded in this decision. Therefore, the veteran's claim that tinnitus should be service connected as secondary to bilateral hearing loss fails because the veteran is not service connected for bilateral hearing loss. See 38 C.F.R. § 3.310(a). Tinnitus could still be service connected on a direct basis. Additionally, the Board notes that the veteran has perfected appeals to the issues of entitlement to service connection for a low back disability and entitlement to service connection for residuals of a left side trunk injury. The low back claim is discussed later in the REMAND portion of the decision and is not affected by the decision on the left side trunk issue. Regarding residuals of a left side trunk injury, a February 1985 radiographic report shows that the veteran injured her ribs on the left side. The chest and left rib series x-rays were reported as within normal limits. According to an October 1987 report of medical history completed by the veteran in connection with the expiration of her term of service, she did not have nor had she had any recurrent back pain. The veteran's October 1987 discharge examination shows a normal clinical evaluation of the spine and abdomen. No defects were noted. An emergency room note from April 1994 relays that the veteran was in a motorcycle accident that day. The reported past medical history did not include any previous back problems or injury. In September 1996 the veteran reinjured her back. The treatment report associated with the reinjury notes that the veteran has a history of L4-5 disc herniation in 1994 after a motorcycle accident. In January 2002, the veteran reported having back pain with numbness down the left leg for the last two months. She reported having felt this before from 1994 to 1999. That same day she reported having been in an automobile accident in 1994 and that she had a herniated disc in 1994. Other treatment records also show reports of low back pain and associated diagnoses; however, there are no such reports between the veteran's separation from service until 1994. A December 2002 private examination shows that an examination of the veteran's spine was within normal limits at that time. Regarding tinnitus and bilateral ear disorder, in August 1981 the veteran reported that she had an ear infection for 3 days. The assessment at that time was upper respiratory infection. A February 1983 airborne examination shows a normal clinical evaluation of the ears. No defects were noted. According to an August 1986 treatment record, a sharp weed penetrated the veteran's ear and ruptured the tympanic membrane. In April 1987, the veteran complained of having a mild earache the day prior. The assessment given shows a normal physical, and that the plan was reassurance and for the veteran to return to the clinic as needed. According to an October 1987 report of medical history completed by the veteran in connection with the expiration of her term of service, she did not have nor had she had ear trouble or hearing loss. The veteran's October 1987 discharge examination shows a normal clinical evaluation of the ears. No defects were noted. In January 1988 the veteran reported that she felt a pop in her right ear after resting with her ear on her upper arm for a long period and that since the pop her ear had been painful. The examiner noted a history of ear drum problem and diagnosed "bilat. Serous otitis m." The Board is of the opinion that this diagnosis is bilateral serous otitis media, a fluid build up in the ear. A private treatment report from November 1988 shows that on examination the veteran's tympanic membranes were clear. On a May 2000 acupuncture intake form, the veteran reported having past ear aches. She did not check the box for now having earaches or for now having ringing in the ears. At the veteran's November 2002 initial visit to the VA Outpatient Clinic in Austin she reported having no tinnitus. A December 2002 private examination shows that an examination of the veteran's ears and tympanic membranes was within normal limits at that time. The veteran was afforded a VA audiological examination in January 2004. The audiologist stated that otoscopic examination revealed intact eardrums, and that the veteran reported at the examination that she did not have tinnitus. Regarding left and right ankle disabilities, a February 1983 airborne examination shows a normal clinical evaluation of the lower extremities. No defects were noted. In April 1983 the veteran complained of right knee and Achilles tendon pain and left ankle pain following a jump. It was noted that she had no past history of injury. On examination the right ankle had some pain with inversion, a full range of motion, and no swelling. The left ankle had no edema and full range of motion. The assessment was minor sprain ankles bilaterally. The veteran was put on light duty for a week, told not to do any physical training for a week, and told to take aspirin. According to an October 1987 report of medical history completed by the veteran in connection with the expiration of her term of service, she did not have nor had she had any foot trouble. While she reported having swollen or painful joints, the physician's summary explains that this related to her knees. The veteran's October 1987 discharge examination shows a normal clinical evaluation of the lower extremities. No defects were noted. On a May 2000 acupuncture intake form, the veteran reported having present foot/ankle pain. A December 2002 private examination report shows that an examination of the veteran's extremities was within normal limits at that time. A July 2007 rheumatology consultation report notes that on physical examination the veteran's ankles were non tender and no swelling was noted. The Board is of the opinion that the above post-service medical evidence shows a current low back disability, but no current residuals of a left side trunk injury, tinnitus, bilateral ear disorder, left ankle disability, or right ankle disability. The veteran's claims for service connection for residuals of a left side trunk injury, tinnitus, bilateral ear disorder, left ankle disability, and right ankle disability fail because there is no competent evidence of record of current diagnoses of any of these disabilities, and without a current disability, service connection cannot be granted. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (Court stated "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability," and held "[i]n the absence of proof of a present disability[,] there can be no valid claim."); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Although the veteran is competent to state that she had and has pain or other common symptoms of disability, she is not competent to enter a diagnosis of a disability, as that requires a medical opinion. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The Board notes that it is obviously aware of the veteran's testimony at the October 2007 hearing before the undersigned Veterans Law Judge. When asked at that hearing if she had ringing in the ears, her answer reflected complaints of hearing loss rather than tinnitus. Prior to that hearing the veteran denied having ringing in the ears on several occasions, and the competent medical evidence of record does not show current tinnitus. In sum, the preponderance of the competent evidence is against a finding of any current residuals of a left side trunk injury, tinnitus, bilateral ear disorder, left ankle disability, and right ankle disability. Thus, service connection is denied, and the benefit-of-the-doubt rule is not for application. See Gilbert, 1 Vet. App. at 55. C. Left foot disability The veteran contends that she has a left foot disability as a result of her service. At her October 2007 personal hearing, the veteran testified that she made between 15 and 20 parachute jumps while in service. She stated that she was not currently receiving treatment for this, besides ice and aspirin, because she would have to take time off work for treatment. According to a February 1981 treatment report, the veteran reported having left foot numbness radiating up her leg. X- rays were reported as within normal limits. A February 1983 airborne examination shows a normal clinical evaluation of the lower extremities and feet. No defects were noted. In October 1984 the veteran reported having right foot pain after a jump. The assessment was contusion. According to an October 1987 report of medical history completed by the veteran in connection with the expiration of her term of service, she did not have nor had she had any foot trouble. The veteran's October 1987 discharge examination shows a normal clinical evaluation of the lower extremities and feet. No defects were noted. On a May 2000 acupuncture intake form, the veteran reported having present foot/ankle pain. In January 2002 the veteran complained to one of her private physicians that she had left foot pain for the last 3 to 4 months. On examination the left foot was tender at the fifth metatarsal and had normal weightbearing and normal range of motion. An x-ray was reported as showing no fracture or deformity and the physician's assessment was left foot pain, occult fracture is still not completely ruled out. A December 2002 private examination shows that an examination of the veteran's extremities was within normal limits at that time. In April 2005 the veteran complained of bilateral foot pain and an assessment from the VA outpatient clinic was bilateral plantar fasciitis. The first showing of any left foot disability is over a decade after the veteran's separation from service. This is strong evidence against a finding of any continuity of symptomatology and against her claim for service connection. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment of the claimed condition for many years after service). Furthermore, there is no indication that the current diagnoses of left foot pain and bilateral plantar fasciitis are related to the veteran's service. While in service the veteran complained of left foot numbness and right foot pain, there was no mention of left foot pain or plantar fasciitis. None of the medical evidence of record suggests that any of the veteran's current left foot complaints are in any way related to her active military service. In fact, in April 2005 the veteran complained of heel pain (diagnosed as plantar fasciitis) after extended walking wearing boots. The veteran specifically denied having foot trouble at her discharge examination. In sum, the preponderance of the competent evidence is against a finding of in-service continuing left foot disability, left foot disability for years after service, and a nexus between the post-service diagnoses of left foot pain and bilateral plantar fasciitis and service. Thus, service connection is denied, and the benefit-of-the-doubt rule is not for application. See Gilbert, 1 Vet. App. at 55. D. Headaches The veteran contends that she currently has headaches as a result of her active military service. At her October 2007 personal hearing, the veteran testified that she currently gets headaches every other week and that she takes aspirin for relief. She relayed that she was treated for headaches while in service that she believes resulted from being around noise, stress, and having to wear a "steel pot" all the time. In December 1981 the veteran reported having headaches for the last 1 or 2 months. The assessment was probable tension headache. In February 1982 the veteran reported that after being dispensed a new eye glass prescription her headaches had resolved. A February 1983 airborne examination shows a normal neurological evaluation. No defects were noted. In September 1985, the veteran reported having a headache and was assessed with having rhinosinusitis. According to an October 1987 report of medical history completed by the veteran in connection with the expiration of her term of service, she did not have nor had she had frequent or severe headaches. The veteran's October 1987 discharge examination shows a normal neurological evaluation. No defects were noted. Documented complaints of headaches are not shown post-service for many years. A review of the veteran's systems on a January 1996 emergency room note states that she did not have any headache symptoms at that time. On a May 2000 acupuncture intake form, the veteran reported having headaches all day, every day. In April 2003, the veteran called a VA outpatient clinic complaining of headaches and pounding ears after starting a medication. She requested a different medication to replace that one. A review of the veteran's systems on a July 2004 consultation report again show that the veteran was not describing headaches. The veteran has reported to her counselor at the Vet Center that she gets headaches when people at work wear perfume. The veteran's service medical records show that the veteran complained of headaches on two occasions. The first complaint from December 1981 seemed to resolve after the veteran was given a different eye glass prescription. The second complaint, in September 1985, was assessed as rhinosinusitis. The veteran's claim for sinusitis is discussed later in the REMAND portion of the decision. There are no documented complaints of headaches from September 1985 until years after the veteran's January 1988 discharge, and the veteran's current headaches have been associated with perfume and medication rather than her service. Simply put, there is no indication that the veteran's current complaints of headaches are in any way related to the headaches she complained of in service. As such, her claim must be denied. In sum, the preponderance of the competent evidence is against a finding of chronic headaches in-service, continuity of symptomatology associated with headaches, and a nexus between current headaches and service. Thus, service connection is denied, and the benefit-of-the-doubt rule is not for application. See Gilbert, 1 Vet. App. at 55. ORDER Entitlement to initial evaluations in excess of 10 percent for patellofemoral pain syndrome, right and left knee, is denied. New and material evidence not having been received, the veteran's application to reopen the claim of entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for post-traumatic stress disorder is granted. Entitlement to service connection for residuals of a left side trunk injury is denied. Entitlement to service connection for tinnitus, to include as secondary to bilateral hearing loss, is denied. Entitlement to service connection for bilateral ear disorder is denied. Entitlement to service connection for left ankle disability is denied. Entitlement to service connection for right ankle disability is denied. Entitlement to service connection for left foot disability is denied. Entitlement to service connection for headaches is denied. REMAND The veteran contends that she has a low back disability and sinusitis as a result of her active military service. As discussed above, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). During the pendency of this appeal, on March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The veteran has not been sent a VCAA notification letter for her claims of entitlement to service connection for low back disability and sinusitis. As such, the Board finds that these claims must be remanded to ensure proper compliance with the VCAA, its implementing regulations, and pertinent case law. The AMC/RO should send the veteran a letter providing proper notification as required by the VCAA and pertinent case law, including Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Turning to another matter, the Board is of the opinion that VA examinations are warranted regarding the veteran's claims for service connection for low back disability and sinusitis. The veteran has submitted competent medical evidence showing a current diagnosis of sinusitis and recurrent symptoms of low back disability. Diagnoses of sinusitis and lumbar strain are shown in service. The available medical evidence along with the veteran's testimony and statements indicate that these disabilities may be related to her active military service. There appears to be insufficient evidence before the Board to make a decision on these issues; accordingly, the veteran should be scheduled for appropriate VA examinations to determine the nature and etiology of sinusitis and any current low back disability. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). Regarding any low back disability, the Board notes that the veteran's October 2007 personal hearing, she testified that she completed 15 to 20 parachute jumps while in service. She also relayed that as a military policewoman, she carried a lot of equipment such as a handgun, flashlight, baton, ammunition, and handcuffs. She first received treatment for her back after service after she was in a motorcycle accident. She relayed that she believed parachute jumps in service contributed to her back condition, and that she did not seek treatment for her back prior to the motorcycle accident because she could not afford to get treatment. A February 1983 Airborne examination shows a normal clinical evaluation of the spine and abdomen. No defects were noted. In December 1983 the veteran reported having a gradual onset of lower back pain since August. The assessment was muscle spasm, and a lumbosacral x-ray was reported as negative. A subsequent consultation note shows an assessment of lumbar strain. According to an October 1987 report of medical history completed by the veteran in connection with the expiration of her term of service, she did not have nor had she had any recurrent back pain. The veteran's October 1987 discharge examination shows a normal clinical evaluation of the spine and abdomen. No defects were noted. An emergency room note from April 1994 relays that the veteran was in a motorcycle accident that day. The reported past medical history did not include any previous back problems or injury. In September 1996 the veteran reinjured her back. The treatment report associated with the reinjury notes that the veteran has a history of L4-5 disc herniation in 1994 after a motorcycle accident. In January 2002, the veteran reported having back pain with numbness down the left leg for the last two months. She reported having felt this before from 1994 to 1999. That same day she reported having been in an automobile accident in 1994 and that she had a herniated disc in 1994. Other treatment records also show reports of low back pain and associated diagnoses; however, there do not appear to be any such reports between the veteran's separation from service and 1994. A December 2002 private examination shows that an examination of the veteran's spine was within normal limits at that time. The examiner addressing the nature and etiology of any current low back disability should be asked to specifically comment on the veteran's 1994 motorcycle accident and the effect that has had, if any, on her low back. Regarding sinusitis, at the veteran's October 2007 personal hearing, she testified that she has continuously taken over the counter medication for sinusitis since her service. A March 1983 treatment record states that the veteran has a history of sinus problems. An in-service treatment record from September 1985 shows a diagnosis of rhinosinusitis. A February 1995 hospital report includes a diagnosis of sinusitis. A November 1998 private treatment record notes that the veteran had a sinus infection at that time. On a May 2000 acupuncture intake form, the veteran reported having past and present sinus problems. February 2003, March 2004, March 2005, and October 2006 VA treatment notes show diagnoses of sinusitis. The veteran's relevant history should be taken into account by the VA examiners. Accordingly, the case is REMANDED for the following action: 1. The veteran should be sent a letter providing proper notification for her claims for service connection as required by the VCAA, its implementing regulations, and pertinent case law, including Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). She should be allowed a sufficient time for response. 2. The veteran should be scheduled for a VA examination to determine the nature and etiology of any current low back disability. The claims folder should be made available to the examiner for review prior to the examination. Any needed non- invasive tests should be performed to determine if the veteran has a current low back disability. If the examiner finds a current low back disability, the examiner should provide an opinion as to whether the veteran currently has any current low back disability that is as likely as not (e.g., a 50 percent or greater probability) attributable to the veteran's service. Any opinion should be accompanied by a written rationale with evidence in the claims file and/or sound medical principles. If an opinion cannot be made without resort to mere speculation the examiner should so state. The examiner should specifically comment on the veteran's 1994 motorcycle accident and any impact that has had on the veteran's low back condition. 3. The veteran should be scheduled for a VA examination to determine the nature and etiology of sinusitis. The claims folder should be made available to the examiner for review prior to the examination. The examiner should provide an opinion as to whether the veteran currently has sinusitis that is as likely as not (e.g., a 50 percent or greater probability) attributable to the veteran's service. Any opinion should be accompanied by a written rationale with evidence in the claims file and/or sound medical principles. If an opinion cannot be made without resort to mere speculation the examiner should so state. 4. The veteran's entire file should then be reviewed and her claim readjudicated. If any benefit sought on appeal remains denied, the veteran and her representative should be furnished an appropriate supplemental statement of the case and afforded the opportunity to respond. Thereafter, the case should be returned to the Board in accordance with applicable procedures. The veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs