Citation Nr: 1314253 Decision Date: 04/30/13 Archive Date: 05/15/13 DOCKET NO. 09-47 475 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for the residuals of colon cancer, to include as due to exposure to herbicides. 2. Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD) and depression. 3. Entitlement to service connection for a low back disability, to include as secondary to the service-connected bilateral knee disabilities. 4. Entitlement to service connection for a right shoulder disability. 5. Entitlement to service connection for a left testicle disability manifested by pain. 6. Entitlement to service connection for bronchitis/asthma. 7. Entitlement to service connection for diabetes mellitus, to include as due to exposure to herbicides. 8. Entitlement to service connection for hypertension, to include as due to exposure to herbicides and/or as secondary to diabetes mellitus. 9. Entitlement to service connection for erectile dysfunction, to include as due to exposure to herbicides and/or as secondary to diabetes mellitus. 10. Entitlement to service connection for a heart disability, to include as due to exposure to herbicides and/or as secondary to diabetes mellitus. 11. Entitlement to a rating in excess of 10 percent for open angle glaucoma. 12. Entitlement to a rating in excess of 10 percent for residuals of a right knee injury. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel INTRODUCTION The Veteran served on active military duty from June 1968 to June 1971 and from April 1972 to April 1989. These issues come before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In that decision, the RO continued and confirmed the previously assigned ratings for open angle glaucoma and a right knee disability, confirmed the prior denials of service connection for new and material evidence claims, and denied all original claims for service connection. The new and material evidence claim for diabetes mellitus was previously recharacterized as a service connection claim. In June 2011, the Veteran testified before the undersigned Veterans Law Judge at a video conference hearing. A copy of the transcript has been reviewed and associated with the file. In December 2011, the Board remanded the claims remaining on appeal to the RO via the Appeals Management Center (AMC) for additional development. In a September 2012 rating decision, the AMC granted service connection for left knee osteoarthritis, chronic allergic rhinitis, headaches, and toenail defects of the left great toe. The decision represented a total grant of the benefits sought on appeal for those issues, and they are no longer before the Board on appeal. In February 2013 the Veteran submitted to the Board additional evidence for consideration in connection with the claims on appeal. A waiver of RO jurisdiction for this evidence was received in a written statement dated in February 2013 that is included in the record. The Board accepts this evidence for inclusion in the record on appeal. See 38 C.F.R. § 20.1304 (2012). The issues of entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depression; service connection for a low back disability; and a rating in excess of 10 percent for open angle glaucoma 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. By a January 1999 rating decision, the RO denied the claim of entitlement to service connection for colorectal cancer. The RO notified the Veteran of the decision in a letter also dated in January 1999; the Veteran did not appeal. 2. Evidence received after the January 1999 RO denial is cumulative and redundant of the record at the time of the prior final denial of service connection for colon cancer and does not raise a reasonable possibility of substantiating the claim. 3. Competent and probative evidence of record fails to establish that a right shoulder disability was initially manifested during service or within one year after separation from service, or that a right shoulder disability is related to active service. 4. The Veteran does not have a current left testicle disability. 5. The Veteran does not have a current bronchitis or asthma disability. 6. The Veteran did not serve in Vietnam and temporary duty assignment on the Korean DMZ between April 1969 and May 1970 when tactical herbicides were used, including Agent Orange, has not been corroborated. 7. There is no convincing evidence that the Veteran was exposed to herbicides during active service. 8. Competent and probative evidence of record fails to establish that diabetes mellitus was initially manifested during service or within one year after separation from service, or that diabetes mellitus is related to active service. 9. Competent and probative evidence of record fails to establish that hypertension was initially manifested during service or within one year after separation from service, or that hypertension is related to active service or to a service-connected disability. 10. Competent and probative evidence of record fails to establish that erectile dysfunction was initially manifested during service, or that erectile dysfunction is related to active service or to a service-connected disability. 11. Competent and probative evidence of record fails to establish that heart disease was initially manifested during service or within one year after separation from service, or that heart disease is related to active service or to a service-connected disability. 12. The residuals of right knee injury with chronic right knee strain has been manifested at worst by extension to 0 degrees, flexion to 60 degrees, and minimal arthritic change confirmed by x-ray evidence. There is no showing of ankylosis; recurrent subluxation or lateral instability; dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint; or malunion or nonunion of the tibia and fibula. CONCLUSIONS OF LAW 1. The RO's January 1999 decision, which denied the claim of entitlement to service connection for colorectal cancer, is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2012). 2. Evidence received since the final January 1999 rating decision is not new and material. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5108, 7105 (West 2002 & Supp. 2012); 38 C.F.R. § 3.156 (2012). 3. The criteria for establishing service connection for a right shoulder disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 4. The criteria for establishing service connection for a left testicle disability manifested by pain have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 5. The criteria for establishing service connection for bronchitis or asthma have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 6. The criteria for establishing service connection for diabetes mellitus, to include as due to exposure to herbicides, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 7. The criteria for establishing service connection for hypertension, to include as due to exposure to herbicides and/or as secondary to the claimed diabetes mellitus disability, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 8. The criteria for establishing service connection for erectile dysfunction, to include as due to exposure to herbicides and/or as secondary to the claimed diabetes mellitus disability, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 9. The criteria for establishing service connection for a heart disability, to include as due to exposure to herbicides and/or as secondary to the claimed diabetes mellitus disability, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 10. The criteria for a rating in excess of 10 percent for residuals of right knee injury with chronic right knee strain have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.20, 4.45, 4.59, 4.71a, Diagnostic Code 5299-5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, in a July 2006 letter, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claims for service connection on a direct and secondary basis and for increased ratings, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The July 2006 letter also advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence that impacts those determinations. In claims to reopen, VA must notify the 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 benefit sought. Kent v. Nicholson, 20 Vet. App. 1 (2006). To satisfy this requirement, VA 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. Id. VA's Office of General Counsel issued informal guidance interpreting the decision in Kent as requiring that the notice provided specifically identify the kind of evidence that would overcome the prior deficiency rather than simply stating the evidence must relate to the stated basis of the prior denial. VA Gen. Couns. Mem., para. 2, 3 (June 14, 2006). In the present case, notice was provided to the Veteran in December 2011 regarding his claim to reopen for service connection for residuals of colon cancer. The Board finds this notice fully complies with VA's duty to notify. The Veteran was advised of the reasons why his claim was previously denied and that new and material evidence must be submitted that addresses the reasons for the prior denial. He was further advised of the types of evidence he needed to submit. Finally, he was advised of what information and evidence was necessary to substantiate the underlying service connection claim. The case was readjudicated in January 2013. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of any notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Board also finds that VA has complied with all assistance provisions of the VCAA, to include substantial compliance with the prior remand. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The evidence of record contains service treatment records, service personnel records, post service private and VA treatment records, lay statements, hearing testimony, and VA examination reports. The Board has also reviewed the Veteran's paperless Virtual VA claims file, a highly secured electronic repository that is used to store and review documents involved in the claims process, and has noted that there are no additional documents in the Virtual VA file not already contained in the paper claims file. There is no indication of relevant, outstanding records that would support the Veteran's claims decided herein. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1)-(3) . The Veteran was not provided with a VA examination to assess his claims for service connection for diabetes mellitus, hypertension, erectile dysfunction, or heart disease, each claimed as due to exposure to herbicides, to include Agent Orange. However, VA need not conduct an examination with respect to these claims on appeal, as information and evidence of record contains sufficient competent medical evidence to decide the claims. See 38 C.F.R. § 3.159(c)(4) (2012); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Specifically, the evidence does not suggest that diabetes mellitus, hypertension, erectile dysfunction, or heart disease manifested during service or that diabetes mellitus, hypertension, or heart disease manifested within the year following discharge, or that they are related to service for reasons other than claimed Agent Orange exposure. Moreover, there is no competent or credible evidence that the Veteran was, in fact, exposed to herbicides as alleged. In addition, because the underlying claim for service connection for diabetes mellitus is denied, the claims of service connection for hypertension, erectile dysfunction, and a heart disability as secondary to diabetes mellitus are denied as a matter of law. Therefore, a VA examination is not warranted for any of the claimed diabetes mellitus, hypertension, erectile dysfunction, or heart disease disabilities. In June 2011, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims recently held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing fulfills two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the June 2011 video conference hearing the undersigned Veterans Law Judge identified the issues on appeal and explained what information was required to substantiate the claimed exposure to herbicides and the service connection and increased rating claims. Information was also obtained to clarify the Veteran's arguments. The appeal was remanded to obtain additional treatment records, to attempt to verify the claimed service on the Korean DMZ, and to obtain VA examinations and medical opinions regarding some of the claims. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. 3.103(c)(2). For all the foregoing reasons, the Board concludes that VA's duties to the Veteran have been fulfilled with respect to the issues decided on appeal. Claims File Review As an initial matter, the Board acknowledges statements from the Veteran expressing concern that VA did not have or review all of the evidence that he submitted in support of his claims. The Board has reviewed all the evidence in the claims file, which currently includes nine volumes (and contains numerous duplicates of medical and lay evidence) and an electronic Virtual VA record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Criteria & Analysis I. Claim to Reopen The Veteran seeks service connection for residuals of colon cancer. The RO originally denied the Veteran's claim in a decision dated in January 1999. He was notified of the denial in a January 1999 letter. The Veteran did not file a notice of disagreement with the decision or perfect a timely appeal of the January 1999 RO decision denying service connection for colorectal cancer. See 38 C.F.R. §§ 20.200, 20.201, 20.202. The RO's January 1999 denial of the claim is therefore final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. The submission of "new and material" evidence is a jurisdictional prerequisite to the Board's review of such an attempt to reopen a claim. Absent the submission of evidence that is sufficient to reopen the claim, the Board's analysis must cease. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed.Cir. 1996); Butler v. Brown, 9 Vet. App. 167, 171 (1996); McGinnis v. Brown, 4 Vet. App. 239, 244 (1993). The Board may not then proceed to review the issue of whether the duty to assist has been fulfilled, or undertake an examination of the merits of the claim. The Board will therefore undertake a de novo review of the new and material evidence issue. As general rule, a claim shall be reopened and reviewed if new and material evidence is presented or secured with respect to a claim that is final. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. When a claimant seeks to reopen a final decision, the first inquiry is whether the evidence obtained after the last disallowance is "new and material." Under 38 C.F.R. § 3.156(a), new evidence means evidence not previously submitted to agency decision makers. Material evidence means 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). Initially, it is noted that the evidence to be reviewed for sufficiency to reopen a claim is the evidence submitted since the most recent final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 271 (1996). When determining whether a claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). In order for evidence to be sufficient to reopen a previously denied claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). Furthermore, "material evidence" could be "some new evidence [that] may well contribute to a more complete picture of the circumstances surrounding the origin of the Veteran's injury or disability, even where it will not eventually convince the Board to alter its rating decision." Hodge v. West, 155 F. 3d 1356, 1363 (Fed. Cir. 1998). If it is determined that new and material evidence has been submitted, the claim must be reopened. VA may then proceed to the merits of the claim on the basis of all of the evidence of record. In Shade v. Shinseki, 24 Vet. App. 110, 117 (2010), the Court interpreted the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." At the time of the January 1999 RO decision denying the claim of entitlement to service connection for colorectal cancer, the evidence of record consisted of the Veteran's service treatment and personnel records, which did not reflect complaints, findings, or diagnosis of colon cancer; private treatment records from the Brooke Army Medical Center, Maxwell Air Force Base (AFB), Dr. R. Miller-Frost, Baptist Medical Center, East Montgomery Medical Center, Alabama Oncology, and Dr. Eaddy; VA treatment records; September 1998 VA joints and eyes examination reports; and statements from the Veteran. Among these records, an August 1996 VA pathology report listed a brief clinical history of rectal bleeding. The microscopic exam/diagnosis was rectosigmoid colon polyp biopsy: invasive moderately differentiated adenocarcinoma. A September 1996 pathological report from Columbia East Montgomery Medical Center revealed metastatic colonic adenocarcinoma. He underwent a right sigmoid colon resection the same month and subsequently underwent chemotherapy treatments. The claim was denied in January 1999 because there was no treatment in service for colorectal cancer and service treatment records showed no findings regarding the claimed colon cancer disability. Subsequently, additional VA examination reports, VA and private outpatient treatment records, and personal statements and testimony by the Veteran have been associated with the claims file. Most of the additionally received evidence is "new" in the sense that it was not previously before the RO at the time of the January 1999 denial. However, the new evidence is not material. The new evidence does not reflect findings or treatment for colon cancer during military service, which was the basis for the January 1999 denial. Similarly, the new evidence does not reflect a diagnosis of colon cancer within one year of separation from service sufficient to warrant service connection on a presumptive basis. In addition, the Veteran's lay statements now asserting that he developed colon cancer due to exposure to Agent Orange while serving on the Korean DMZ from April 1969 until May 1970 fail to raise a reasonable possibility of substantiating the claim because colon cancer is not included in the list of diseases associated with exposure to herbicides. See 38 U.S.C.A. § 1116 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309. Therefore, even assuming that the claimed exposure to Agent Orange in Korea was credible for purposes of reopening the claim, entitlement to service connection for colon cancer would not warranted on a presumptive basis due to herbicide exposure. 38 C.F.R. §§ 3.307, 3.309. Unfortunately, none of the additional evidence includes any competent medical evidence or medical opinion that the colon cancer diagnosed in September 1996 was a result of military service. The Board finds the evidence added to the claims file since the January 1999 RO decision is either cumulative or redundant of the evidence of record or does not relate to an unestablished fact necessary to substantiate the claim for service connection for residuals of colon cancer. Under these circumstances, the Board must conclude that new and material evidence to reopen the claim for service connection for residuals of colon cancer has not been received. As such, the requirements for reopening the claim are not met. As the Veteran has not fulfilled his threshold of submitting new and material evidence to reopen his finally disallowed claim, the benefit-of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). II. Service Connection Claims Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Right Shoulder Certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1133; 38 C.F.R. §§ 3.307, 3.309. The Veteran contends that he has a right shoulder disability that was incurred during military service and aggravated by his service-connected right and left knee disabilities. A September 1981 emergency record indicates that the Veteran was a passenger in an accident and complained of injury to his right shoulder and right leg. The diagnosis included contusion of the right clavicle. September 1981 right clavicle and right shoulder x-ray reports revealed no fracture. During follow-up treatment in October 1981, he stated that he was involved in a car accident nine days earlier and complained of decreased range of motion and pain. On examination, his right shoulder and right knee were swollen. The assessment was shoulder and right knee injury. During October 1981 follow-up treatment, the Veteran stated that his right shoulder hit a tree and his right leg was caught in the car. He reported pain in his collar bone and on the right side of his neck. The assessment included right sternoclavicular joint separation versus fracture. An October 1981 right clavicle x-ray was reported as normal. In reports of medical examination dated in June 1968, February 1971, May 1978, October 1981, and February 1983, clinical evaluation of the upper extremities was reported as normal. In a May 1988 report of medical history, the Veteran denied currently or ever having painful or "trick" shoulder or elbow. In a February 1989 retirement report of medical history, he reported a painful or "trick" shoulder or elbow. A physician's summary elaborated that the Veteran was treated for a dislocated shoulder due to an auto accident in 1981. On retirement examination in February 1989, clinical evaluation of the upper extremities was reported as normal. During an October 1994 post-service allergy clinic visit at Maxwell AFB, the Veteran denied musculoskeletal problems, including joint pain, swelling, or stiffness, during a review of systems. A June 1999 private treatment record from K. Thompson, M.D., reflects that the Veteran denied joint pain. On examination, no significant muscle, bone, or joint finding was present. During a February 2001 VA annual examination, the Veteran reported left shoulder pain, but did not identify any right shoulder pain. In a February 2006 VA nursing screening note, the Veteran's subjective complaints included bilateral shoulder pain. Objective findings regarding the right shoulder were not reported. His claim for service connection for a right shoulder disability was received in February 2006. During a June 2011 video conference hearing, the Veteran indicated that his contentions were outlined in a June 2011 statement that he mailed to the Board prior to the hearing. In that statement, he asserted that he severely injured his shoulder during an in-service automobile accident. The Veteran was afforded a VA joints examination in March 2012. He reported noting pain in his right shoulder in 1981 without any history of specific injury and that he was advised to rest and placed on light duty. He described right shoulder pain that radiated to his neck. He stated that he was told that he had arthritis. The impression of a right shoulder x-ray was minimal degenerative changes of the glenohumeral joint with a small ossific spur from the neck of the humerus. Following a review of the claims file and physical examination, the examiner opined that it was less likely as not that the minimal degenerative changes described on x-ray of the right shoulder were related to the injury of the right shoulder/right sternoclavicular joint hematoma noted in 1981 following a motor vehicle accident. Supporting the conclusion, the examiner noted that service treatment records reflected that the right clavicular area hematoma had resolved and post-service records did not reveal any diagnosis of a shoulder condition. The examiner emphasized that VA primary care records showed that the Veteran was regularly followed, and except for chronic knee problems, none of the other orthopedic notes showed ongoing problems with the right shoulder. The Board has considered the medical and lay evidence of record, but finds that service connection for a right shoulder disability is not warranted. As detailed, service treatment records reveal a right shoulder injury sustained during a car accident in September 1981 that resulted in a contusion of the right clavicle. X-ray studies revealed no fracture. No further right shoulder complaints were documented among service treatment records after the October 1981 follow-up evaluation. While the lack of in-service findings of complaints or diagnosis of a chronic right shoulder disability in service does not preclude a finding of service connection, as detailed minimal degenerative changes of the right shoulder were not shown until March 2012, thus over 22 years after separation from service. The Board finds an absence of any subjective complaints of right shoulder problems for more than two decades after discharge from service or of persistent symptoms of right shoulder degenerative changes between service-discharge and his 2006 claim, and an absence of any objective evidence of right shoulder degenerative changes for over 22 years after discharge from service. The lack of any evidence of continuing right shoulder problems for many years between the period of active duty and the initial findings or documented complaints of right shoulder problems weighs against the claim. A prolonged period without medical complaint can be considered, along with other factors concerning the claimant's health and medical treatment during and after military service, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability which still exists currently. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Likewise, a March 2012 VA examiner reviewed the claims file, which included service treatment records. As detailed, the examiner opined that the Veteran's current minimal degenerative changes of the right shoulder were not related to the injury of the right shoulder/right sternoclavicular joint hematoma noted in 1981 following a motor vehicle accident based on review of the claims folder. The examiner stated that service treatment records reflected that the right shoulder injury had resolved and that post-service treatment records relating to orthopedic complaints did not show ongoing right shoulder problems. The opinion of the VA examiner leads to a finding that the Veteran's degenerative right shoulder disability is less likely than not related to service. The Board accepts the examiner's opinion as being the most probative medical evidence on the subject, as such was based on a review of all historical records, and contains detailed rationale for the medical conclusion that is consistent with and supported by the evidence of record. See Boggs v. West, 11 Vet. App. 334 (1998). Given the depth of the examination report, and the fact that the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). There is also no contrary opinion of record. The Board has considered the Veteran's contention that a relationship exists between his current right shoulder disability and the 1981 injury experienced during a car accident in service. In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). In this capacity, the Board finds the Veteran is competent to attest to the car accident he experienced in September 1981 during service. However, the Veteran is not competent to provide an opinion that his current degenerative right shoulder disability is due to that remote accident as he does not have the requisite medical expertise. The fact remains that after October 1981 further complaints or evaluation for right shoulder problems are not documented in service treatment records, and although he endorsed currently or previously having painful or "trick" shoulder or elbow at separation examination, clinical evaluation of the upper extremities was reported as normal. Moreover, post-service treatment records document the Veteran's denials of joint problems prior to February 2006. The Veteran's contentions are outweighed by the medical evidence and opinion of the VA medical examiner which reflect that his degenerative right shoulder disability is not due to military service, including the 1981 injury. The negative clinical and documentary evidence post service for more than two decades after service is more probative than the remote assertions of the Veteran. The lack of continuity of treatment may bear in a merits determination on the credibility of the evidence of continuity of symptoms by lay parties. Savage v. Gober, 10 Vet. App. 488, 496 (1997). The question involved regarding causation is medical in nature. As discussed above, the medical opinion of the VA medical examiner (based on a review of the claims file and with knowledge of the Veteran's in-service complaints) was negative. Under these circumstances, the Board is unable to find that there is a state of equipoise of the positive evidence and negative evidence. The preponderance of the evidence now of record is against the Veteran's claim of service connection for a right shoulder disability. Left Testicle The Veteran's claim for a left testicle disability was received in February 2006. He asserted that he currently has severe pain in his left testicle and referred generally to his service treatment records and to VA treatment records in support of his claim. In July 1988, a urology consultation request was placed to evaluate for any pathology because the Veteran reported that he had been married for 16 years, but did not have children. A semen analysis was reported to be within the lower limits of normal. The provisional diagnosis was borderline semen analysis. The assessment of an August 1988 urology consultation was oligospermia, rule out stricture. September 1988 urology follow-up notes for idiopathic oligospermia indicated that there were no strictures. He was started on a trial of Clomid. The impression was oligospermia. A February 1989 retirement report of medical history noted that current medications included Clomid. A February 1989 treatment note indicated that the Veteran completed a 90-day Clomid treatment and the medication was discontinued. A post-service report from the Brooke Army Medical Center (BAMC) dated in June 1989 revealed testosterone within the normal range. In a June 1997 private treatment record for follow-up regarding adjuvant therapy for Duke's C carcinoma of the colon, the Veteran reported some occasional discomfort in his scrotum or testicles. The assessment included scrotal discomfort of uncertain etiology that may well be musculoskeletal. During November 1998 treatment with R. Miller-Frost, M.D., the Veteran reported pain in the testicles, most recently the left, off and on over the last several days. He stated that he could not discern any abnormality on his own exam. The physician could not identify a problem on examination, including any masses, tenderness, or hernias. She recommended a referral to a urologist. In November 2002, the Veteran reported right testicle pain for 36 hours that was very tender the day before, but improved to the point of minimal discomfort at present. He recalled that a urologist prescribed an antibiotic in 1998 when he had similar symptoms. However, Dr. Miller-Frost indicated that she did not receive a report from the urologist, and the Veteran could not remember the urologist. Examination was reported as unremarkable; however, he was given tetracycline and advised to see a urologist on a regular basis given his cancer history. During a February 2001 VA annual examination, the Veteran did not identify any testicle problems. Reported objective findings included no mass felt testicle, scrotum. The Veteran was afforded a VA examination in March 2012. He stated that he had a low sperm count in service and had testicle pain for a long period of time. He reported seeing a urologist in the past who told him that there was no scrotal mass or testicular mass, but he was given pain medication and [anti-]inflammatory medications. He described constant, random pain in the left testicle not related to any activity. Following a review of the claims file and physical examination, the examiner opined that the symptom of pain in the left testicle with mild tenderness of the epididymis was less likely than not related to the symptoms noted in the military (urinary tract infection, urethral discharge, and oligospermia). Having reviewed the entire claims file, the Board finds that service connection for a left testicle disability is not warranted. Initially, the Board acknowledges that the Veteran is competent to describe symptoms of his claimed left testicle disability such as pain. See Barr v. Nicholson, 21 Vet. App. 303 (2007). However, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, diagnosing a testicle disorder and determining the etiology of such falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Thus, the Board accords significantly greater probative value to the medical evidence of record than to the Veteran's lay assertions on these points. In this case, the Board finds that service connection for a left testicle disorder is not warranted because there is no evidence of a current left testicle disability. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. § 1110. Where, as here, the claims file is void of any competent medical evidence establishing that the Veteran currently has a left testicle disability, the condition for which service connection is sought is not established, and thus, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). While the Veteran reported testicle pain in June 1997, November 1998, and November 2002, pain alone without a diagnosed or identifiable underlying malady or condition does not in and of itself constitute disability for which service connection may be granted. Sanchez- Benitez v. West, 13 Vet. App. 282, 285 (1999) appeal dismissed in part, and vacated and remanded in part, Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). In this case, the current medical evidence, including a VA examination specifically for the claimed left testicle disorder, does not reflect current disability of the testicle. Accordingly, service connection for the claimed condition of left testicle pain is not warranted. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Bronchitis/Asthma The Veteran's claim for service connection for "bronchitis/asthma" was received in February 2006. He cited a service treatment record "dated 1971" in support of his claim. Service treatment records reflected complaints of allergy and hay fever symptoms, including headaches. As noted in the introduction, a September 2012 rating decision granted service connection for chronic allergic rhinitis and headaches. Chest x-rays dated in April and November 1970 were reported as normal. In a February 1971 separation report of medical history, the Veteran indicated that he had asthma, shortness of breath, and pain or pressure in his chest. A physician's summary referred to a chest consultation and noted that the Veteran was cleared for separation. A March 1971 chest consultation described a history of intermittent cough with a small amount of sputum production, shortness of breath on exertion, and a smoking habit of one-half to two packs per day for five years [since 1966]. The examiner commented that the Veteran most probably had bronchitis from smoking and the dry, dusty climate. The impression was bronchitis. An August 1972 chest x-ray was reported as negative. A February 1982 service treatment record reflects the Veteran's complaint of a cold for the past five days with non-productive cough. On examination, his chest was congested with wheezing in both lungs. The assessment was cold. In September 1982 the Veteran complained of allergy symptoms and requested an allergy consultation. He denied coughing problems. During an August 1988 urology consultation, the Veteran indicated that he smoked for approximately 13 years until a year ago [from 1974 to 1987]. In a summary of care, the Veteran reported that he quit tobacco in 1987 after smoking one and a half packs for ten years [since 1977]. A September 1988 chest x-ray for retirement examination was reported as normal. In a February 1989 retirement report of medical history, the Veteran checked "yes" to currently or ever having asthma and shortness of breath, but crossed out and initialed the "yes" checkmarks and instead clearly checked the "no" boxes corresponding to asthma and shortness of breath. He checked "yes" to frequent or severe headache, sinusitis, and chronic cough. A physician's summary elaborated that his cough was attributed to allergy and his headaches to Clomid. The physician noted that the Veteran had complied with the recommendation to quit smoking in relation to a sinus disorder. During an October 1994 post-service allergy clinic visit at Maxwell AFB, the Veteran denied pulmonary problems, including cough or wheezing, during a review of systems. However, the impression of a pulmonary function test (PFT) was mixed dysfunction with moderate restrictive pattern and a mild obstructive component. The physician recommended a complete PFT. The diagnosis of a December 1994 PFT was minimal obstructive airway disease, possible emphysema. During private treatment at the Maxwell AFB in January 1995 for allergies, the Veteran denied pulmonary symptoms of cough, sputum, hemoptysis, or wheezing during a review of systems. During a February 2001 VA annual examination, the Veteran denied current respiratory problems, including asthma. A July 2005 VA PFT report identified the Veteran's current complaint as shortness of breath with activity for the past six months. He reported smoking one to one and a half packs per day for ten years and quitting 20 years ago. He denied taking any prescribed respiratory medications. The report noted that the Veteran's abdominal weight could affect the results because he admitted to gaining 10 to 15 pounds. The interpretation of the PFT was a mild obstructive lung defect. During a June 2011 video conference hearing, the Veteran indicated that his contentions were outlined in a June 2011 statement that he mailed to the Board prior to the hearing. In that statement, he asserted that he had bronchitis and asthma during military service and that the conditions had worsened. The Veteran was afforded a VA examination in March 2012. He stated that in the past he was treated for bronchitis infrequently but there was no definite history of asthma. He denied using any inhalers or nebulizer treatments for asthma. Following a review of the claims file; physical examination; and pulmonary function testing, which revealed a mild obstructive lung defect; the examiner concluded that the Veteran did not have a current asthma disability. The examiner also concluded that there was no chronic bronchitis disability because the evidence of record reflected a past history of bronchitis treated one time. In correspondence dated in February 2013, the Veteran stated that he had a long history of taking medication, such as Flovent, for his bronchitis that was prescribed by a private doctor. The Board has considered the medical and lay evidence of record, but finds that service connection for bronchitis or asthma is not warranted. Again, the Board acknowledges that the Veteran is competent to describe symptoms of his claimed bronchitis or asthma disability such as coughing, wheezing, or shortness of breath. See Barr, supra. However, diagnosing a respiratory disorder and determining the etiology of such falls outside the realm of common knowledge of a lay person. See Jandreau, supra. Thus, the Board accords significantly greater probative value to the medical evidence of record than to the Veteran's lay assertions on these points. In addition to considering competence, the Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U. S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In fact, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In weighing the credibility of lay assertions, the Board may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). To the extent the Veteran asserts that he had a long history of taking prescribed medication for bronchitis, the Board finds that he is not a credible historian. First, his February 2013 assertion in this regard is contradicted by an earlier statement made in July 2005 in which he denied taking any prescribed respiratory medications. (He also denied using any inhalers or nebulizer treatments for asthma during the March 2012 VA examination). Similarly, his February 2013 statement claiming a long history of taking medication for bronchitis is inconsistent with his admission on VA examination in March 2012 that he was treated for bronchitis infrequently in the past and unsupported by the post-service medical evidence of record, which does not reflect diagnosis or treatment for bronchitis. In this case, the Board finds that service connection for bronchitis or asthma is not warranted because there is no evidence of a current bronchitis or asthma disability. Here, the Veteran himself admitted during his March 2012 VA examination that he had no definite history of asthma and was treated only infrequently for bronchitis after the single diagnosis of bronchitis during service in March 1971. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. § 1110. Where, as here, the claims file is void of any competent medical evidence establishing that the Veteran currently has asthma or a chronic bronchitis disability, the condition for which service connection is sought is not established, and thus, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the current medical evidence, including private treatment records and PFT reports and a VA examination specifically for the claimed bronchitis or asthma disorder, does not reflect current bronchitis or asthma disability. Accordingly, service connection for the claimed condition of bronchitis or asthma is not warranted. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Exposure to Herbicides During Service in Korea on the DMZ The Veteran contends that he has diabetes mellitus, hypertension, erectile dysfunction, and heart disease due to exposure to herbicides, to include Agent Orange, while serving on the Korean demilitarized zone (DMZ). In his February 2006 claim for service connection, he asserted that he was present on the Korean DMZ and exposed to Agent Orange during both of his tours in Korea while attached to various units for two-month periods. He specified that from [April] 1969 to May 1970 he served in the Air Defense Artillery as a Red Eye fire team leader and artillery forward observer attached to the 1st of the 9th Infantry, 1st of the 72nd Armor, 2nd of the 38th Infantry, and 2nd of the 38th Infantry. He asserted that he was exposed to Agent Orange while on the Korean DMZ during his second tour when attached for two months each to the 1st of the 23rd Infantry, 1st of the 9th Infantry, 2nd of the 23rd Infantry, and 3rd of the 23rd Infantry. A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a). A veteran is entitled to a presumption of service connection if he is diagnosed with type 2 diabetes mellitus, or other enumerated diseases, associated with exposure to certain herbicide agents, if he served in the Republic of Vietnam during a prescribed period. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.313(a); see also Haas v. Peake, 525 F.3d 1168, 1197 (Fed. Cir. 2008) (upholding VA's interpretation of section 3.307(a)(6)(iii) as requiring the servicemember's presence at some point on the landmass or the inland waters of Vietnam). The Department of Defense (DoD) has identified specific units that served in areas along the DMZ in Korea where herbicides were used between April 1968 and July 1969. See VA's Adjudication Procedure Manual, M21-1MR, Part IV, Subpart ii, Chapter 2, Section C.10.o. Recently, 38 C.F.R. § 3.307 was amended to include service between April 1, 1968, and August 31,1971 in a unit that, as determined by the Department of Defense, operated in or near the Korean DMZ in an area in which herbicides are known to have been applied during that period. 76 Fed. Reg. 4245-01 (Jan. 15, 2011) (to be codified at 3.307(a)(6)(iv)). Service personnel records confirm service in Korea from April 1969 to May 1970 and from January 1976 to February 1977. During his first tour in Korea, his principal duty was listed as missile launcher mechanic with Battery A, 7th Battalion (Hawk), 2nd Artillery. During his second tour in Korea, his principal duties were listed as IH A CH Fir Sec Mechanic with B Battery 2/71st ADA; Track Vehicle Mechanic with B Battery, 1st Battalion, 2nd ADA; and IH A CH HPI Mechanic with A Battery, 1st Battalion, 2nd ADA. Service personnel records do not reflect temporary duty assignment (TDY) to the Korean DMZ during either tour in Korea. Service treatment records dated in July, August, November, and December 1969 and in April 1970 reflect that the Veteran received treatment at the 6045th USAF Hospital at Osan Air Base Korea. (The Board notes that according to the U.S. Air Force, the Osan AB is located 48 miles south of the Korean DMZ. See http://www.osan.af.mil/newcomers/ (last visited Apr. 23, 2013)). In a July 2001 report of contact, the Veteran indicated that he was never in country in Vietnam. In his substantive appeal received in December 2009, the Veteran asserted that many of the issues he had claimed were clearly indicated in his service medical records, but many of his service medical records were lost during military service. He also stated that TDY status does not require permanent orders or annotation to DA Form 2-1, military service record. During the June 2011 video conference hearing, he claimed that his diabetes, hypertension, and heart disease, among other claimed disabilities, were due to exposure to Agent Orange. He claimed that he served on the Korean DMZ in 1969 and 1970 during his first tour there during TDY missions with particular units, which he had previously identified. He referred to a June 2011 statement outlining his contentions that he had mailed to the Board prior to the hearing. In that statement, he clarified that in his duties as a Red Eye team leader he was "required to be next to the DMZ to observe enemy actions (North Korean security positions) and report via radio to the main artillery command." In April 2012 correspondence, the Veteran clarified that he served in the unit of the 1st Battalion, 2nd Air Defense Artillery, 38th Air Defense Brigade, but he was attached to the 1st of the 9th Infantry; 1st of the 72nd Armor, and the 2nd of the 38th Infantry by unit (company) orders on a temporary basis for two months each on the Korean DMZ from 1969 to 1970. In October 2012, the AMC sent a request to Joint Services Records and Research Center (JSRRC) to attempt to verify the Veteran's claimed exposure to tactical herbicides, to include Agent Orange, while serving at or near the DMZ while serving in Korea. In November 2012 the Defense Personnel Records Information Retrieval System (DPRIS) responded to the request as follows: We reviewed the 1969-1970 unit histories submitted by the 7th Battalion, 2nd Artillery (7th Bn, 2nd Arty) and its higher headquarters, the 38th Arty Brigade (Bde). The histories document that the Headquarters, 7th Bn, 2nd Arty was located at Shihung-ni Compound, approximately seventeen miles from the DMZ. The 38th Arty Bde was made up of one Hercules Battalion and four Hawk Battalions. They were dispersed from Chunchon, near the DMZ, to Kunsan. However, the histories do not document the use, storage, spraying, or transporting of herbicides. In addition, they do not mention or document any specific duties performed by the unit members along the DMZ. Subsequently, in a November 2012 memorandum, the AMC JSRRC coordinator made a formal finding regarding the lack of information needed to corroborate a claim associated with the exposure to herbicides; determined that the evidence failed to confirm that the Veteran was exposed to tactical herbicides, to include Agent Orange, in Korea; and detailed efforts taken to corroborate the claimed exposure. The memorandum indicated in accordance with M21-1 MR IV.ii.2.C.10.p that the Veteran's unit, Battery A, 7th Battalion (HAWK), 2nd Artillery, is not a unit recognized as having been exposed to herbicides in Korea between April 1, 1968 and August 31, 1971. The memorandum also noted the negative response from the JSRRC. The memorandum also indicated that upon a thorough review the Veteran's full personnel and service treatment records, there was no indication that the Veteran served in Korea with any unit other than Battery A, 7th Battalion (HAWK), 2nd Artillery between April 1969 and May 1970, and there was no indication that he was officially assigned to any other unit for TDY at the time. Finally, the memorandum explained that according to M21-1MR IV.ii.2.C.10.p, the Veteran's additional time period of service in Korea between 1976 and 1977 succeeded those dates recognized as dates within which a Veteran was presumed to have been exposed to herbicides while in country. As an initial matter, the Board finds that competent evidence of record fails to establish that the Veteran served on the Korean DMZ during his tour in Korea between April 1969 and May 1970 when herbicides were used and the presumption of exposure to an herbicide agent under 38 C.F.R. § 3.307 does not apply herein. Therefore, the presumption provisions of this regulation are not applicable. Notwithstanding the foregoing presumption provisions, which arose out of the Veteran's Dioxin and Radiation Exposure Compensation Standards Act, Public Law No. 98- 542, § 5, 98 Stat. 2725, 2727-29 (1984), and the Agent Orange Act of 1991, Public Law No. 102-4, § 2, 105 Stat. 11 (1991), the Federal Circuit has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom. Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). See Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). Thus, presumption is not the sole method for showing causation. Accordingly, the Board's adjudication below will include consideration of whether service connection may be awarded for diabetes mellitus, hypertension, erectile dysfunction, and heart disease on a direct incurrence basis. Diabetes Mellitus Certain chronic disabilities, such as diabetes mellitus, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1133; 38 C.F.R. §§ 3.307, 3.309(a). Service treatment records are silent for complaints, findings, or diagnosis of diabetes. In a summary of care, the Veteran reported a family history of diabetes mellitus. In a February 1989 retirement report of medical history, the Veteran denied recent gain or loss of weight or frequent or painful urination. On retirement examination, clinical evaluation of the endocrine system was reported as normal, urinalysis was reported as negative, and glucose testing was reported as 134 and 124 on repeat. A post-service treatment record from the Maxwell AFB dated in July 1992 indicates that the Veteran had reported a family history of diabetes mellitus and wanted screening; a glucose test was performed two weeks earlier. The assessment was rule out diabetes mellitus. An August 1992 note indicates that glucose was 183 and the physician left a message for the Veteran to call. In an October 1992 telephone note, the physician reported fasting glucose levels to the Veteran and recommended a diet consult with follow-up fasting blood sugar testing after two months. An October 1992 dietician consultation request indicated that the Veteran had newly diagnosed diabetes mellitus. In April 1993, the assessment was follow-up adult onset diabetes mellitus. In a September 1994 private treatment record from Maxwell AFB, the Veteran reported urinating a lot, weakness, fatigues, and blurred vision with a positive family history of diabetes. He stated that he recently finished the laboratory tests that were ordered. The assessment was adult onset diabetes mellitus. A private treatment record dated in March 1997 from R. Miller-Frost, M.D., indicates that the Veteran was referred regarding a new onset of diabetes mellitus and other problems associated with current chemotherapy treatment for metastatic carcinoma of the colon. The Veteran stated that he was previously told that he had diabetes several years ago, he went on a diabetic diet, exercised, lost 30 pounds, and his blood sugars normalized. However, upon being encouraged to eat while on chemotherapy, he had been eating quite liberally and gained weight. The impression was adult onset diabetes mellitus, currently uncontrolled. A November 2001 private treatment record from S. Owens, M.D., indicates that the Veteran reported a strong family history of diabetes and that he had been diabetic since 1992. Subsequent private and VA treatment records reflect ongoing evaluation and treatment for diabetes mellitus. During a June 2011 video conference hearing, the Veteran reiterated his assertion that he had diabetes due to exposure to herbicides as a result of TDY service on the Korean DMZ during his first tour in Korea. The Board has considered the medical and lay evidence of record, but finds that service connection for diabetes mellitus is not warranted. Considering the claim for service connection for diabetes mellitus on a direct basis, the Board notes that none of the service medical records reflects complaints, findings, or diagnosis of an endocrine disorder, to include diabetes. Rather examination reports during service consistently documented a normal endocrine system. Service connection on a presumptive basis must be denied because competent medical evidence of record reflects that diabetes mellitus was first diagnosed in October 1992 and does not reflect that diabetes mellitus was otherwise manifested to a compensable degree within one year of separation from service. In summary, the preponderance of the evidence is against a finding that the Veteran served on the Korean DMZ, and there is no other evidence corroborating his claimed exposure to herbicides in service. Moreover, the evidence does not show that his diabetes arose during service or within one year of separation from service, or is otherwise related to service. In fact, he repeatedly identified a family history of diabetes mellitus to various treatment providers. Therefore, the claim for service connection for diabetes mellitus is denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Hypertension The Board notes that the term hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (2012). Certain chronic disabilities, such as hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1133; 38 C.F.R. §§ 3.307, 3.309(a). A compensable, 10 percent, disability rating is warranted when diastolic pressure is predominantly 100 or more, or; systolic pressure is predominantly 160 or more, or; when an individual has a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. See 38 C.F.R. § 4.104, Diagnostic Code 7101. Service connection may also be established if the evidence of record shows that a chronic disorder has been caused or aggravated by an already service-connected disability. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that effective October 10, 2006, 38 C.F.R. § 3.310 was amended; however, under the facts of this case the regulatory change does not impact the outcome of the appeal. As previously discussed, there is sufficient evidence to indicate the Veteran was exposed to Agent Orange while serving on active duty. Although hypertension is not among the diseases recognized by VA as associated with herbicide exposure, see 38 C.F.R. § 3.309(e), Note 3, service connection may still be granted if the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir.1994). The Veteran contends that he has hypertension due to exposure to Agent Orange and as secondary to his claimed diabetes mellitus disability. Among numerous service treatment records, diastolic blood pressure was not predominantly 90mm or greater. Rather, diastolic pressure was recorded as 90 or greater only on four occasions, in April 1987, May 1988, September 1988, and February 1989. Systolic blood pressure was never recorded as 160 or greater during service; instead, the highest systolic blood pressure was recorded as 140 in April 1989. On enlistment examination in June 1968, the Veteran's blood pressure was recorded as 110/80. On separation examination in February 1971, his blood pressure was recorded as 130/80. Other reports of medical examination recorded his blood pressure as follows: 130/80 (February 1971, separation), 110/70 (April 1972), 128/80 (September 1975), 124/74 (May 1978), 130/82 (October 1981), 130/86 (February 1983), and 112/94 (February 1989, retirement). In reports of medical history, the Veteran denied currently or ever having high or low blood pressure, except in May 1988 and on retirement examination in February 1989 when he indicated that he did not know whether he had high or low blood pressure. A September 1988 retirement electrocardiographic record listed the Veteran's blood pressure as 110/94. The February 1989 report of medical history noted the Veteran's reported family history of elevated or high blood pressure in his mother, father, sister, and brother. The conclusion of a March 1991 post-service echocardiogram was normal echocardiogram. In a September 1994 private treatment record from Maxwell AFB, the Veteran's blood pressure was recorded as 140/89. The assessment included borderline hypertension. The plan included monitor blood pressure and weight loss. During a review of systems at the allergy clinic in October 1994, the Veteran denied hypertension. His blood pressure was recorded as 140/88. In November 1994, he participated in a 5-day blood pressure check. The results were reported as follows: Right Arm Left Arm Day 1 134/92 130/90 Day 2 120/90 124/86 Day 3 118/82 N/A Day 4 120/84 N/A Day 5 132/82 N/A The assessment was borderline hypertension and the plan included another 5-day blood pressure check. During a March 1997 consultation with a private physician, R. Miller-Frost, M.D., for a new onset of diabetes mellitus while being treated for colon cancer, the Veteran denied other significant medical history, other than glaucoma, including high blood pressure. In an August 1998 treatment note, Dr. R. Miller-Frost indicated that the Veteran's blood pressure, primarily the diastolic reading, had been borderline high recently. On that day, it was recorded as 120/90. An oncology flow sheet from K. Thompson, M.D., indicated that as of September 1998 medications included Lopressor. An October 1998 treatment record from Dr. R. Miller-Frost reflects the Veteran's report of fairly consistent diastolic blood pressure readings in the low 90s. A low dose of Lopressor was prescribed for some blood pressure lowering effects as well as for headaches. In November 1998, he reported that he stopped taking the Lopressor because he had been checking his blood pressure and not finding a problem and subsequent blood pressures evidently were good as well. In June 1999, he indicated that he generally was not taking his Lopressor and his blood pressure had been excellent; it was recorded as 130/84. In a July 2002 history and physical report from Dr. R. Miller-Frost, the impression included hypertension, currently satisfactorily controlled. The assessment of a June 2005 VA primary care note included hypertension controlled. The impression of a July 2005 echocardiogram included mild pulmonary hypertension. During a May 2006 VA cardiology consultation, the Veteran reported having longstanding diabetes and hypertension and a "bad family history of coronary heart disease," as well as smoking for "quite some time," but not recently. The cardiologist noted that testing done around one year earlier included mild pulmonary hypertension on echocardiogram. He also noted that the pulmonary function tests revealed mild chronic obstructive pulmonary disease, which was probably what accounted for the mild pulmonary hypertension. Subsequent private and VA treatment records reflect ongoing evaluation and treatment for hypertension. The Board has considered the medical and lay evidence of record, but finds that service connection for hypertension, to include as due to exposure to herbicides and as secondary to diabetes mellitus, is not warranted. Considering the claim for service connection for hypertension on a direct basis, the Board notes that none of the service medical records reflects complaints, findings, or diagnosis of hypertension. While service treatment records reflect four diastolic blood pressure readings of 90 or greater between April 1987 and February 1989, the service medical evidence plainly does not reflect diastolic blood pressure recorded as predominantly 90mm or greater or systolic blood pressure that was ever recorded as 160mm or greater during service. Service connection for hypertension on a presumptive basis must be denied because competent medical evidence of record reflects that hypertension was first diagnosed around August 1998 when the Veteran's physician reported that his diastolic readings had been borderline high recently and when the Veteran reported in October 1998 that his diastolic readings were fairly consistently in the low 90s. The evidence does not reflect that hypertension was manifested to a compensable degree within one year of separation from service because the evidence in the year following separation from service does not include diastolic blood pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; a history of diastolic pressure predominantly 100 or more with continuous medication required for control. Also, to the extent that the Veteran contends that service connection for his hypertension is warranted as secondary to his diabetes mellitus, as the Board herein denies service connection for diabetes mellitus, there is no legal basis for granting service connection for hypertension as secondary to diabetes mellitus. Where, as here, service connection for the primary disability has been denied, the Veteran cannot establish entitlement to service connection, pursuant to 38 C.F.R. § 3.310(a), for a secondary condition. Thus, the matter of service connection for hypertension as secondary to a diabetes mellitus disability is without legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Erectile dysfunction The Veteran's claim for service connection for "erectile dysfunction (impotence)" was received in February 2006. He asserted that he had erectile dysfunction as a direct result of exposure to Agent Orange and as secondary to his claimed diabetes mellitus disability. As previously discussed, there is sufficient evidence to indicate the Veteran was exposed to Agent Orange while serving on active duty. Although erectile dysfunction is not among the diseases recognized by VA as associated with herbicide exposure, see 38 C.F.R. § 3.309(e), Note 3, service connection may still be granted if the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir.1994). During an August 1988 urology consultation to evaluate the Veteran for any pathology in relation to a borderline semen analysis, he completed an infertility history questionnaire. He answered "yes" to having "any difficulties with erections or ejaculation," and specified that the difficulty involved "small volume, painful ejaculate." The assessment was oligospermia, rule out stricture. On retirement examination in February 1989, clinical evaluation of the genitourinary system was reported as normal. In a post-service July 1990 treatment record from Maxwell AFB, the Veteran reported recurrent foreskin tears. The assessment was phimosis. Following an August 1990 urology consultation and examination, the assessment was balanitis. The plan included circumcision. A November 1990 follow-up note indicated that the Veteran underwent an uneventful circumcision. In a November 1990 pathological report, the diagnosis was mild chronic posthitis of foreskin. During a review of systems at the allergy clinic in October 1994, the Veteran denied sexual dysfunction. During treatment in January 1995 for allergies, a review of systems was negative for genitourinary symptoms including sexual dysfunction. A February 2001 VA annual examination report reflects reports of urinary symptoms, but does not include reports of sexual dysfunction. During January 2004 VA primary care treatment, the Veteran reported a recent onset of erectile dysfunction for two months [since November 2003]. The assessment included erectile dysfunction and medications were started. During March 2005 VA primary care treatment, the Veteran requested an increase in erectile dysfunction medications. Having reviewed the entire claims file, the Board finds that service connection for erectile dysfunction, to include as due to exposure to herbicides and as secondary to diabetes mellitus, is not warranted. As detailed, service treatment records do not reveal any complaints or treatment for erectile dysfunction, and the first subjective report of erectile dysfunction was made in January 2004 when the Veteran reported an onset in November 2003, thus over 13 years after separation from service. The Board finds an absence of any subjective complaints of erectile dysfunction for more than 13 years after discharge from service. The lack of any evidence of erectile dysfunction during service along with the Veteran's explicit denials of sexual dysfunction after service and report of a November 2003 onset of erectile dysfunction weighs against the claim. A prolonged period without medical complaint can be considered, along with other factors concerning the claimant's health and medical treatment during and after military service, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability which still exists currently. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The Board acknowledges the diagnosis of oligospermia and report of painful ejaculation during service in August 1988. However, the Veteran has not claimed entitlement to service connection for oligospermia or for his symptom in 1988 of painful ejaculation. Rather, he claimed entitlement to "erectile dysfunction (impotence)" and this disability is not shown by post-service medical evidence, including the Veteran's subjective complaints to medical providers, until November 2003. Also, to the extent that the Veteran contends that service connection for his erectile dysfunction is warranted as secondary to his diabetes mellitus, as the Board herein denies service connection for diabetes mellitus, there is no legal basis for granting service connection for erectile dysfunction as secondary to diabetes mellitus. Where, as here, service connection for the primary disability has been denied, the Veteran cannot establish entitlement to service connection, pursuant to 38 C.F.R. § 3.310(a), for a secondary condition. Thus, the matter of service connection for erectile dysfunction as secondary to a diabetes mellitus disability is without legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Heart Disability The Veteran's claim for service connection for heart disease was received in February 2006. He contends that he has heart disease due to exposure to herbicides, to include Agent Orange, and as "secondary to hypertension diabetes mellitus." Service treatment records were void of complaints, findings, or diagnosis of heart problems. In a May 1988 report of medical history, the Veteran checked "yes" to currently or ever having pain or pressure in his chest. He denied palpitation or pounding heart or heart trouble. A September 1988 retirement electrocardiographic record summarized that there was a left axis deviation and borderline short P-R int.; otherwise normal. In a February 1989 retirement report of medical history, he checked "yes" to currently or ever having shortness of breath, but he blacked-out and initialed the "yes" checkmark and clearly checked "no" instead. He also denied currently or ever having palpitation or pounding heart or heart trouble. On examination, clinical evaluation of the heart and vascular system was reported as normal. A September 1990 post-service treatment note from Maxwell AFB reflects the Veteran's complaint of shortness of breath and heart palpitations. He stated that his symptoms usually started with headache, then palpitation and feeling weak and dizzy. The assessment was palpitation, headache. In a September 1990 follow-up note, the physician noted that a glaucoma medication was discontinued in the emergency room because it was thought to cause palpitation. The Veteran indicated that his palpitations were resolving and he denied shortness of breath and dizziness. The assessment was history of palpitation. In another September 1990 follow-up note after a Holter monitor test, the assessment was resolving palpitation. In January 1991, he complained of left chest pain for a day and a half with intermittent palpitation. The assessment was chest pain, atypical in nature. During a March 1997 consultation with a private physician, R. Miller-Frost, M.D., for a new onset of diabetes mellitus while being treated for colon cancer, the Veteran denied other significant medical history, other than glaucoma, including heart disease. A September 1997 discharge summary from Baptist Medical Center indicates that the Veteran was admitted with increasing shortness of breath, especially upon exertion, over the course of a week as well as mid sternal chest tightness radiating up to his left arm. Serial 12-lead EKGs and cardiac enzymes were obtained, which were reported as normal, and a thallium GXT [graded exercise test] study was clinically and electrically negative. The discharge diagnosis included unstable angina. The assessment of an October 1997 chest x-ray was no evidence of acute changes. A June 1999 private treatment record from K. Thompson, M.D., reflects that the Veteran denied cardiac symptoms. During a February 2001 VA annual examination, the Veteran denied any current heart disease. During March 2005 VA primary care treatment, the Veteran reported having "gas pains" from Metamucil. The assessment included "gas" - candidate for cardiac workup/note ED - but not classic angina symptoms. An addendum note indicated that EKG revealed right bundle branch block (RBBB) and inferior T waves. A May 2005 report from Montgomery Cardiovascular Associates to evaluate angina pectoris indicated that a nuclear laboratory and stress testing revealed normal findings. A May 2006 cardiology clinic nursing note indicated that the Veteran presented for a cardiology consultation to rule out pulmonary hypertension. He reported a history of hypertension since 1990 and being diabetic. He described early morning chest pain that goes away on its own after 30 minutes and shortness of breath on exertion and inclines. He disclosed that his mother expired at age 55 from heart problems; a sister was diagnosed in her late 30s with congestive heart failure, had a defibrillator, and was diabetic; and a brother expired at age 59 from heart failure. During a cardiology consultation on the same day, the Veteran reported having longstanding diabetes and hypertension and a "bad family history of coronary heart disease." He described atypical chest pains off and on for quite some time and some dyspnea on exertion. The cardiologist noted that testing done around one year earlier included a normal stress Cardiolite and a slightly reduced ejection fraction, mild pulmonary hypertension, and no valvular dysfunction on echocardiogram. The Veteran expressed concern about his atypical chest pain because of his "terrible family history" and the cardiologist believed that another perfusion scan was in order as a result. In an addendum note, the cardiologist noted that he doubted ischemic pain, but the Veteran had many risk factors. Subsequent private and VA treatment records associated with the claims file did not reflect diagnosis or treatment for heart disease. In correspondence dated in February 2013, the Veteran reiterated his assertion that he has a current heart disability due to Agent Orange exposure and stated that he has an abnormal EKG with blockage. Having reviewed the entire claims file, the Board finds that service connection for heart disease, to include as due to exposure to herbicides and as secondary to diabetes mellitus, is not warranted. Considering the claim for service connection for heart disease on a direct basis, the Board notes that none of the service medical records reflects complaints, findings, or diagnosis of a heart disorder or heart disease. Clinical evaluation of the heart and vascular system was reported as normal on separation examination in February 1989. Service connection on a presumptive basis must be denied because competent medical evidence of record reflects that a right bundle branch block (RBBB) was first diagnosed by VA EKG in March 2005. While post-service treatment records in September 1990 and January 1991, more than one year after separation from service, included complaints of palpitations (and chest pain in 1991), those symptoms were not shown to be chronic as reflected by subsequent treatment records. Moreover, the Veteran denied any current heart disease in March 1997 and in February 2001, and in May 2006 he reported a family history of heart problems, heart failure, and coronary artery disease. In summary, the preponderance of the evidence is against a finding that the Veteran served on the Korean DMZ, and there is no other evidence corroborating his claimed exposure to herbicides in service. Moreover, the evidence does not show that his claimed heart disease arose during service or within one year of separation from service, or is otherwise related to service. Therefore, the claim for service connection for heart disease is denied. Finally, to the extent that the Veteran contends that service connection for any heart disease is warranted as secondary to his diabetes mellitus or hypertension, as the Board herein denies service connection for diabetes mellitus and hypertension, there is no legal basis for granting service connection for heart disease as secondary to diabetes mellitus or hypertension. Where, as here, service connection for the primary disability has been denied, the Veteran cannot establish entitlement to service connection, pursuant to 38 C.F.R. § 3.310(a), for a secondary condition. Thus, the matter of service connection for heart disease as secondary to a diabetes mellitus or hypertension disability is without legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). III. Increased Rating Claim - Residuals of Right Knee Injury Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; assigning the higher rating where there is a question as to which of two evaluations apply and where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath, 1 Vet. App. at 594. However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, 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, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. It should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The Veteran's residuals of right knee injury, chronic right knee strain is rated as 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5299-5261. For purposes of this decision, the Board notes that normal range of motion for the knee is flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71, Plate II. Diagnostic Codes 5260 and 5261 provide for rating based on limitation of motion. Evaluations for limitation of flexion of a knee are assigned as follows: flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; and flexion limited to 15 degrees is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Evaluations for limitation of extension of the knee are assigned as follows: extension limited to 10 degrees is 10 percent; extension limited to 15 degrees is 20 percent; extension limited to 20 degrees is 30 percent; extension limited to 30 degrees is 40 percent; and extension limited to 45 degrees is 50 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating is warranted for symptomatic removal of the semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. A higher rating is not available under this Diagnostic Code. A June 2006 private treatment note from R. Hester, M.D., reflects the Veteran's complaint of right knee joint line pain and tenderness. On examination he had pain with flexion and with McMurray testing. X-rays reportedly showed minimal arthritic change. Dr. Hester believed that the Veteran had a little degenerative meniscal tear and possibly a little arthritis. He received a Lidocaine and Triamcinolone injection for pain. His claim for an increased rating for a right knee disability was received in August 2006. He enclosed a copy of his February 2006 claim in which he requested service connection for left and right knee disabilities, although the right knee disability was already service-connected. He stated that he could not walk upright. The Veteran was afforded a VA joints examination in February 2007. The examiner indicated that the Veteran's history regarding his right knee was somewhat confusing because he first remembered having surgery on his right knee during military service; however, when the examiner could not locate any surgical scar, he stated that he did not recall if he had surgery on his right knee. He believed that he injured his right knee during military service and had "torn cartilage." He recalled having surgery on his left knee in 2006, going to physical therapy, and having good results. At present, he complained of pain, stiffness, flare-ups every two weeks, and using a cane sometimes for three days when his knees flare up. He indicated that he worked as a program analyst with no change in job duties due to his knees. He stated that he could not walk because of his knees, but he could previously walk one mile three to four times a week. On examination of the knees, both appeared normal with no swelling or deformity. A surgical scar on the right knee was not located. On range of motion testing, the Veteran had full extension without pain bilaterally and flexion to 140 degrees bilaterally with complaints of pain throughout the last 10 degrees of flexion bilaterally. No additional limitation was seen with repetitive motion. Both knees were stable and gait was normal. X-rays of both knees revealed mild bilateral patella spurring; the right knee also had bony fragments in the region of the medial collateral ligament. The diagnosis was mild chronic strain of the right knee. The Veteran was afforded another VA joints examination in February 2009. He stated that he could walk up to a quarter of a mile and that he had orthoscopic surgery in the private sector in 2006. He reported intermittent sharp right knee pain, radiating up to his back, with three flare-ups per day each lasting 30 to 40 minutes. He stated that walking increased his pain. He denied requiring assistive aids. He indicated that since retirement from military service in 1989, he had worked as a software developer. He also stated that he had been excused from performing duties at work that involve bending, stooping, or lifting. He believed that his right knee problem had caused his left knee to have difficulty. On examination, he was observed to walk in a rhythmic and symmetric fashion without limp and not appearing to be in pain. Right knee range of motion testing revealed full extension and flexion to 80 degrees; the Veteran could not be encouraged to flex any further. After repetitive use, there was no increased loss of motion due to pain, fatigue, weakness, lack of endurance, or incoordination. There was no anterior/posterior or mediolateral instability. The Veteran had some tenderness medially, more so than laterally. There was no joint swelling, heat, or redness noted. There were three 1cm scars present from arthroscopic surgery. No crepitus or patellofemoral pain was noted. X-rays were not performed because the Veteran had been sent for them on several occasions. The diagnosis was status post arthroscopic surgery, right knee. The examiner concluded that at the present time the Veteran was experiencing a mild to moderate disability from his right knee condition. During July 2009 VA primary care treatment, the Veteran's complaints included constant knee pain. The assessment included ambulatory without problems, gait steady, denies any falls or injuries. During the June 2011 hearing, the Veteran testified that he received treatment for his right knee one time in the last two years at Southern Orthopedics and that he received treatment approximately every 90 days for his right knee at the Montgomery VAMC. He testified that his treatment consisted of "pain pills" that he received from VA. In a December 2011 letter, the Appeals Management Center (AMC) enclosed three copies of VA Form 21-4142, Authorization and Consent to Release Information, and asked the Veteran to complete and return the form to allow VA to assist him in obtaining any additional treatment records pertinent to his right knee disability. The AMC asked him to notify VA if he had not received any treatment for his right knee disability. A July 2011 VA primary care record reflects the Veteran's complaint of bilateral knee pain of 7 to 8/10 on most days with flare-ups of pain associated with walking and getting up from a sitting position. He reported popping and instability on the right. On examination the right knee had no warmth and no medial lateral movement. During a January 2012 VA PTSD examination, the Veteran stated that he currently works full-time, participates one hour per day on household chores, and participates in household shopping. He was observed walking within normal limits by the examining clinical psychologist. The Veteran was afforded a VA joints examination in March 2012 to evaluate his claimed right knee disability. He reported chronic, constant knee pain rated as a 9/10, daily swelling, difficulty getting up after prolonged sitting, and popping and cracking. He stated that he was currently prescribed Tylenol with Codeine for knee problems and pain. He indicated that he used a cane as needed, but did not bring it with him to the examination. Right knee range of motion testing included flexion to 60 degrees with objective evidence of pain at 50 degrees and extension to 0 degrees with objective evidence of pain beginning at 20 degrees. He was unable to perform repetitive use testing because he reported pain with range of motion and refused to do further range of motion. The examiner remarked that there was a great deal of difficulty encouraging him to do any further range of motion. As a result, the examiner explained, he could not comment about additional limitation of range of motion. The examiner indicated that the Veteran did have functional loss and functional impairment of his knee with less movement than normal and a moderate amount of pain. However, he believed that the Veteran exaggerated his symptoms. Additional objective findings on right knee examination included tenderness or pain to palpation of the joint line or soft tissues, 4/5 muscle strength, patellar subluxation/dislocation not appreciated, and faint arthroscopic surgical scars that were not painful or unstable. The Veteran reported that he currently worked as a computer programmer and was exempt from lifting heavy files because of his knees. He stated that he takes a shuttle from the parking lot to the entrance of his workplace. In correspondence dated in February 2013, the Veteran indicated that he had an appointment with a private orthopedic doctor later the same month to receive treatment and braces for both his knees and that he would submit a medical summary within two weeks of the appointment. He did not indicate that his right or left knee disability had increased in severity. More than 60 days after the scheduled appointment, no further medical evidence has been received from the Veteran. The Board has carefully considered the medical and lay evidence of record, but finds that a rating in excess of 10 percent for residuals of right knee injury, chronic right knee strain is not warranted. The Veteran's right knee disability has been manifested at worst by extension to 0 degrees, flexion to 60 degrees, and minimal arthritic change confirmed by x-ray evidence. These findings do not warrant a compensable rating for limitation of flexion under Diagnostic Code 5260 or for limitation of extension under Diagnostic Code 5261. A higher rating for a right knee disability is not warranted under any potentially applicable provision because the medical evidence of record does not demonstrate any right knee ankylosis; recurrent subluxation or lateral instability; dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint; or malunion or nonunion of the tibia and fibula. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256 through 5262. The Board has considered 38 C.F.R. §§ 4.40 and 4.45, addressing the impact of functional loss, weakened movement, excess fatigability, incoordination, and pain. DeLuca, 8 Vet. App. at 206-07. However, an additional "symbolic" rating for range of motion loss for pain, excess fatigability, decreased functional ability, etc. is not warranted. As detailed, the March 2012 VA examiner noted that the Veteran's right knee disability affected his work as a computer programmer because he was exempt from lifting heavy files. His functional impairment due to such symptoms as pain has been considered in assigning the 10 percent disability rating for the right knee. While acknowledging the effects on his employment as reflected in the March 2012 VA examination report, there is no basis for a higher rating based on additional functional loss due to pain, weakness, impaired endurance, fatigue, incoordination, or flare-ups. In fact, the March 2012 VA examiner believed that the Veteran had exaggerated his right knee symptoms. The Board observes that this conclusion appears to be supported by the evidence of record. For example, in his February 2006 claim, the Veteran stated that he could not walk upright due to his knee and he refused to attempt repetitive motion testing on VA examination in March 2012. However, his gait has been observed to be steady, and on VA PTSD examination in January 2012 he was observed to walk within normal limits. Similarly, while he has reported right knee instability, none has been shown by objective medical evidence. Therefore, the Veteran's subjective complaints do not support a higher rating for a right knee disability. In summary, the Board has considered the assertions by the Veteran pertaining to his right knee disability. However, the Board concludes that the medical findings on examination are of greater probative value than the Veteran's allegations regarding the severity of his right knee disability. Accordingly, a rating in excess of 10 percent is not warranted for a right knee disability, and the claim for a higher rating must be denied. The Board has also considered whether staged ratings are appropriate and concludes that the criteria for an increased rating have not been met at any time during the period on appeal. Therefore, staged ratings for the right knee disability are not warranted for any portion of the current appeal period. The Board has considered whether the Veteran's right knee disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extraschedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's right knee disability level and symptomatology, and provide for higher ratings for additional or more severe symptomatology than is shown by the evidence. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for a higher rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER The application to reopen the previously denied claim of entitlement to service connection for residuals of colon cancer is denied. Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a left testicle disability manifested by pain is denied. Entitlement to service connection for bronchitis or asthma is denied. Entitlement to service connection for diabetes mellitus, to include as due to exposure to herbicides, is denied. Entitlement to service connection for hypertension, to include as due to exposure to herbicides and/or as secondary to diabetes mellitus, is denied. Entitlement to service connection for erectile dysfunction, to include as due to exposure to herbicides and/or as secondary to diabetes mellitus, is denied. Entitlement to service connection for a heart disability, to include as due to exposure to herbicides and/or as secondary to diabetes mellitus, is denied. Entitlement to a rating in excess of 10 percent for residuals of a right knee injury is denied. REMAND The Veteran has a right to substantial compliance with the Board's remand orders. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Moreover, if the Board proceeds with final disposition of an appeal, and the remand orders have not been complied with, the Board itself errs in failing to ensure compliance. Stegall, 11 Vet. App. at 271. Thus, while the Board regrets the additional delay in this case, for the reasons discussed, the case must be returned to the RO/AMC to obtain an additional medical opinion regarding the claimed back disability and to determine whether Goldman perimeter charts, which the February 2009 VA examiner indicated that he used for visual field testing, are available. As noted in the previous remand, the Board asked that a VA orthopedic examiner provide a medical opinion as to whether there is a 50 percent probability or greater (likely, unlikely or as likely as not) that any diagnosed back disability was caused or aggravated by service. If not, the examiner should determine whether there is a 50 percent probability or greater (likely, unlikely or as likely as not), that any back disability is caused or aggravated by the service-connected right knee disability. A review of a March 2012 VA examination and a November 2012 addendum reveals that the Veteran was examined and the requested medical opinions were provided following a review of the claims file, except for the issue of whether any diagnosed back disability was aggravated by the service-connected right knee disability. Therefore, the Veteran should be afforded an additional VA examination to obtain a medical opinion as to whether his service-connected bilateral knee disability caused or aggravates any current back disability. As noted in the previous remand, the Board also directed the RO/AMC to associate with the file the visual field chart referenced in the February 2009 VA examination. If unavailable, the Veteran was to be notified and a negative response was to be documented in the file. In the February 2009 VA examination report, the examiner indicated that "visual fields were charted using a Goldmann Perimeter Chart and included as part of the examination report." A November 2012 letter to the Montgomery VA Medical Center (VAMC) reflects that the AMC requested the visual field chart referenced in the Veteran's February 2009 VA examination. The AMC asked for a response in writing if the records were unavailable. The same month, the Montgomery VAMC provided copies of Heidelberg retina tomographs and photo images of the Veteran's eyes from the February 2009 VA examination and field of vision charts from examinations on other dates. Unfortunately, a field of vision chart from the February 2009 VA examination was not received, nor did the Montgomery VAMC indicate in the November 2012 letter to the AMC that the requested record was unavailable. Moreover, although it appears that the requested chart was not obtained, a January 2013 supplemental statement of the case listed Goldman eye chart from the February 2009 VA examination among the new evidence received. The claim for an increased rating for glaucoma must be remanded again to attempt to locate the February 2009 field of vision chart. The Board also finds that additional development is required regarding the claim for an acquired psychiatric disorder, to include PTSD and depression. The Veteran contends that he has PTSD and depression due to events during military service, and in particular, due to witnessing the torture of North Korean infiltrators by South Koreans in June 1969 while serving on the DMZ. More recently, he claimed that one or more automobile accidents during military service were traumatic for him. In a June 2011 statement, the Veteran indicated that he received treatment for depression during service and for alcohol use during service, which he used to "block the pain of recurring memories of the DMZ incidents" as well as a traumatic automobile accident in May 1972 in which he "nearly lost [his] life." His service treatment records are silent for complaints, findings, diagnosis, or treatment of psychiatric disorders, including PTSD or depression. Service personnel records reflect generally outstanding performance evaluations prior to 1985. A March 1985 letter of reprimand reflects that the Veteran refused to submit to a lawfully requested blood alcohol test in October 1984. The reprimand indicated that the Army had consistently emphasized the tragic consequences of driving after drinking, but the Veteran ignored this. The Deputy Commander emphasized that the Veteran was expected to set and observe high standards for young soldiers to follow because he was a senior member of the Army. The Veteran acknowledged the reprimand in April 1985 and declined to make a statement on his behalf. A May 1985 evaluation report reflected generally high performance, but identified a problem with developing subordinates in their technical skills. An August 1985 evaluation report reflected a significant decrease in professional competence and standards as compared to prior evaluations. The report detailed an inability to effectively lead troops, demonstrated by an inability to maintain high standards, lack of initiative especially in the area of unwillingness to seek self-improvement in physical fitness. The report also identified poor military appearance in the wear of his uniform; lacking loyalty and integrity in himself as a soldier as demonstrated in his absence of duty from an appointed place at an appointed time without regard to troops or chain-of-command and in being untruthful about his whereabouts; and attitude that needed improvement. The indorser indicated that the Veteran did have the potential for improvement; however, it would require a significant change in his attitude and motivation. A September 1986 letter to the Veteran notified him of an imposed bar to reenlistment and his service options. In an October 1986 letter, the Veteran reported that he had corrected all indicated shortcomings or deficiencies since a determination to bar him from reenlistment. He requested to be allowed to complete his current enlistment for retirement purposes. Others recommended approval of the request to reach retirement eligibility. A February 1987 letter indicated that the imposed bar to reenlistment would remain in effect because the Veteran's lack of judgment and self discipline were found to be inconsistent with the high standards of professionalism expected of a non-commissioned officer. An August 1987 treatment note indicates that the Veteran was in the Track 2 program and was advised to seek Antabuse. He reported heavy weekend drinking, but denied alcohol-related legal problems. He stated that his last drink was a month and a half earlier. He received a prescription for Antabuse. In a May 1988 report of medical history, the Veteran endorsed frequent trouble sleeping and depression or excessive worry. A May 1988 mental status evaluation report revealed the following: normal behavior, full alertness, full orientation, unremarkable mood or affect, clear thinking process, normal thought content, and good memory. The examiner concluded that the Veteran had the mental capacity to understand and participate in proceedings, was mentally responsible, and met retention requirements. A summary of care listed the Veteran's occupation as master mechanic and indicated that the Veteran quit alcohol in 1987, admitting to heavy alcohol use for ten years prior. In a February 1989 retirement medical history report, the Veteran denied currently or ever having frequent trouble sleeping, depression or excessive worry, loss of memory or amnesia, or nervous trouble of any sort. On examination, clinical evaluation of psychiatric functioning was reported as normal. The Veteran was afforded a VA PTSD examination by a clinical psychologist in January 2012. In correspondence received in March 2012, he requested a new VA examination because he was not comfortable talking to the examiner about his personal life history and PTSD, which he struggled with for over 30 years. He stated that during the past week he was involved in a "very disturbing event that caused many people to be very uncomfortable. [He] was later counseled" and advised to seek some type of medical intervention for his anger. The RO/AMC should attempt to obtain any active duty mental health and substance abuse treatment records that may be maintained separately from the Veteran's service treatment records. In addition, the RO/AMC should request relevant ongoing VA medical records from the Montgomery VAMC dated from June 2006 to the present. See 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should attempt to obtain and associate with the claims file the following records: (a) any active duty mental health and substance abuse treatment records that may be maintained separately from the Veteran's service treatment records; (b) ongoing treatment records (pertinent to the claims for low back, psychiatric, and glaucoma disabilities) from the Montgomery VAMC dated from June 2006 to the present; and (c) the visual field chart referenced in the February 2009 VA examination. All attempts to procure records should be documented in the file. If the RO/AMC cannot obtain records identified by the Veteran or determines that a February 2009 visual field chart is unavailable, a notation to that effect should be inserted in the file. The Veteran and his representative, if any, are to be notified of unsuccessful efforts in this regard to allow him the opportunity to obtain and submit those records for VA review. 2. Schedule the Veteran for an orthopedic examination to evaluated the claimed back disability. The claims file and a copy of this remand must be made available to and be reviewed by the examiner in conjunction with the examination. The examiner must indicate in the examination report that the claims file was reviewed in conjunction with the examination. All necessary tests should be conducted. The examiner should determine whether there is a 50 percent probability or greater (likely, unlikely or as likely as not) that any diagnosed back disability is aggravated by the service-connected right and left knee disabilities. If an increase in severity for any back disability is found to be due to the service-connected right and left knee residuals, the examiner should identify the baseline level of the back disability (prior to aggravation) and the permanent, measurable increase in the severity of the back disability due to the service-connected right and left knee disabilities. A medical analysis and rationale are to be included with all opinions expressed. 3. After the development in Directive #1 has been completed to the extent possible, schedule the Veteran for a comprehensive VA psychiatric examination with a male psychiatrist or psychologist to determine the diagnoses of all psychiatric disorders that are present. The claims folder and a copy of this remand must be provided to the examiner prior to the examination. The examiner should determine the diagnoses of any currently manifested psychiatric disorder(s), to include PTSD and depression. The diagnosis(es) must be based on examination findings, all available medical records, complete review of comprehensive testing for PTSD, and any special testing deemed appropriate. A multiaxial evaluation based on the current DSM-IV diagnostic criteria is required. The examiner should be advised that the Veteran's alleged TDY service on or near the Korean DMZ has not been verified. The examiner should provide an opinion as to whether it is at least as likely as not (i.e., a likelihood of 50 percent or more) that any currently diagnosed psychiatric disorder, to include PTSD and depression, is a result of service or any incident therein. A complete rationale for all opinions expressed must be provided. The copy of the examination report and all completed test reports should thereafter be associated with the claims folder. 4. After undertaking any other development deemed appropriate and ensuring that the requested actions are completed, the RO or AMC should readjudicate the claims of service connection for a low back and psychiatric disabilities and the claim for in increased rating for glaucoma. If any benefit is not granted in full, the Veteran and his representative, if any, should be furnished with a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant 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. 2012). ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs