Citation Nr: 1007002 Decision Date: 02/25/10 Archive Date: 03/05/10 DOCKET NO. 08-16 411 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial compensable evaluation for hypertension. 2. Entitlement to service connection for posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for a right arm scar. 4. Entitlement to service connection for a skin rash. 5. Entitlement to service connection for a right inguinal hernia. 6. Entitlement to service connection for bilateral shin splints. 7. Entitlement to service connection for migraine headaches. 8. Entitlement to service connection for residuals of a left knee injury. 9. Entitlement to service connection for a low back disorder. 10. Entitlement to service connection for residuals of a left shoulder separation. 11. Entitlement to service connection for the residuals of an injury to the fingers of the right hand. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Scott Shoreman, Associate Counsel INTRODUCTION The Veteran had active service from April 2003 to April 2006. This matter comes before the Board of Veterans' Appeals (Board) from a June 2007 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). The issues of service connection for shin splints and the residuals of a left shoulder separation are herein REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will provide notice when further action is required by the appellant. FINDINGS OF FACT 1. The Veteran's hypertension is characterized by diastolic pressure predominantly less than 100 mm and systolic pressure predominantly less than 160 mm. 2. The competent and probative medical evidence of record preponderates against a finding that the Veteran has PTSD which is related to active military service or any incident thereof. 3. The competent and probative medical evidence of record preponderates against a finding that a right arm scar is related to active military service or any incident thereof. 4. The competent and probative medical evidence of record preponderates against a finding that a skin rash is related to active military service or any incident thereof. 5. The competent and probative medical evidence of record preponderates against a finding that a right inguinal hernia is related to active military service or any incident thereof. 6. The competent and probative medical evidence of record preponderates against a finding that migraine headaches are related to active military service or any incident thereof. 7. The competent and probative medical evidence of record preponderates against a finding that residuals of a left knee injury are related to active military service or any incident thereof, and arthritis is not shown to have been manifested either in service or within one year after separation from service. 8. The competent and probative medical evidence of record preponderates against a finding that a low back disorder is related to active military service or any incident thereof, and arthritis is not shown to have been manifested either in service or within one year after separation from service. 9. The evidence of record is in approximate balance as to whether residuals of an injury to the fingers of the right hand were incurred in service. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for hypertension are not met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2009); 38 C.F.R. § 4.2, 4.7, 4.10, 4.104, DC 7101 (2009). 2. PTSD was not incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.304 (2009). 3. A scar on the right arm was not incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. 4. A skin rash was not incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. 5. A right inguinal hernia was not incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. 6. Migraine headaches were not incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. 7. Residuals of a left knee injury were not incurred in or aggravated by active service, nor may the residuals of a left knee injury be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 8. A low back disorder was not incurred in or aggravated by active service, nor may a low back disorder be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 9. Giving the benefit of the doubt to the Veteran, residuals of an injury to the fingers of the right hand were incurred in service. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating a claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2009). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1) as amended, 73 Fed. Reg. 23,353 (April 30, 2008). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental SOC (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has held that an error in VCAA notice should not be presumed prejudicial, and that the burden of showing harmful error rests with the party raising the issue, to be determined on a case-by-case basis. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). In this case, the appellant has not demonstrated any prejudicial or harmful error in VCAA notice. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). In October 2006 VA sent the Veteran a letter informing him of the types of evidence needed to substantiate his claim and its duty to assist him in substantiating his claim under the VCAA. The letter informed the Veteran that VA would assist him in obtaining evidence necessary to support his claim, such as medical records, employment records, or records from other Federal agencies. He was advised that it is his responsibility to provide or identify, and furnish authorization where necessary for the RO to obtain, any supportive evidence pertinent to his claim. See 38 C.F.R. § 3.159(b)(1). Although no longer required, the appellant was also asked to submit evidence and/or information in his possession to the RO. The Board finds that the content of the letter provided to the Veteran complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify and assist. In addition, the June 2007 rating decision, April 2008 SOC, and October 2008 SSOC explained the basis for the RO's action, and the SOC and SSOC provided him with additional periods to submit more evidence. It appears that all obtainable evidence identified by the Veteran relative to his claim has been obtained and associated with the claims file, and that neither he nor his representative has identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. It is therefore the Board's conclusion that the Veteran has been provided with every opportunity to submit evidence and argument in support of his claims, and to respond to VA notices. In addition to the foregoing harmless-error analysis, we note that the decision of the Court in Dingess v. Nicholson, 19 Vet. App. 473 (2006) requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date. This requirement was fulfilled in the October 2006 letter which VA sent to the Veteran. Accordingly, we find that VA has satisfied its duty to assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claim under the VCAA. Therefore no useful purpose would be served in remanding this matter for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefits flowing to the Veteran. The Court of Appeals for Veteran Claims has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court of Appeals for Veterans Claims held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. II. Relevant Law, Factual Background, and Analysis Service connection may be granted for disability which is the result of disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2009); 38 C.F.R. § 3.303(a) (2009). Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). When the disease identity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances lay evidence of a nexus between the present disability and the symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96; see Hickson v. West, 12 Vet. App. 247, 253 (1999) (lay evidence of in- service incurrence is sufficient in some circumstances for purposes of establishing service connection). Service connection may be granted for disease that is diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). The U.S. Court of Appeals for Veterans Claims has held that, in order to prevail on the issue of service connection, there must (1) be medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in- service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in- service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995); aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. As provided by 38 U.S.C.A. § 1154(a), VA is required to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Citing Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) and Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit has stated that competent medical evidence is not required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Instead, under section 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition, the lay person is reporting a contemporaneous medical diagnosis, or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In addition, the law provides that, where a veteran served ninety days or more of active military service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two evaluations shall be assigned, the higher evaluation will be assigned of the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons used to support the conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. § 4.1, which requires that each disability be viewed in relation to its history and that there be an emphasis placed upon the limitation of activity imposed by the disabling condition, and 38 C.F.R. § 4.2, which requires that medical reports be interpreted in light of the entire recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. These requirements for the evaluation of the complete medical history of the claimant's condition operate to protect claimants against an adverse decision based upon a single, incomplete, or inaccurate report, and to enable VA to make a more precise evaluation of the disability level and any changes in the condition. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Also, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). A. Increased Evaluation for Hypertension The Veteran is seeking an initial compensable evaluation for his service-connected hypertension. A 10 percent evaluation is warranted with diastolic pressure predominantly 100 mm or more or systolic pressure predominantly 160 mm or more. In addition, 10 percent is the minimum evaluation to be assigned for an individual with a history of diastolic pressure at predominantly 100 or more who requires continuous medication for control. A 20 percent evaluation requires diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent disability requires diastolic pressure at predominantly 120 or more, and a 60 percent evaluation requires diastolic pressure predominantly at 130 or more. 38 C.F.R. § 4.104, DC 7101. June 2006 to September 2006 VA treatment records show that the Veteran's systolic blood pressure ranged between 131 and 156 and his diastolic blood pressure ranged between 69 and 91. In January 2008 the Veteran had a VA examination for hypertension. It was noted that at his separation from service he was taking ramipril 10 mg and metoprolol 50 mg. At the time of the examination the Veteran was taking lisinopril 20 mg daily to control his blood pressure. Blood pressure readings at the examination were 150/96, 148/92, and 143/89. He was diagnosed with hypertension, controlled with medication. At October 2007 treatment the Veteran's blood pressure was 130/84, and in April 2008 it was 149/79 and 176/110. After a careful review of the evidence of record, the Board finds that entitlement to an initial compensable evaluation for the service-connected hypertension has not been established. The evidence of record does not show that the Veteran's blood pressure has been manifested by diastolic pressure at predominantly 100 or more or by systolic pressure at predominantly 160 or more, as required by DC 7101. In addition, although the Veteran's hypertension requires continuous medication for control, he does not have a history of diastolic pressure predominantly 100 or more. Given the blood pressure readings noted above, the preponderance of the competent evidence is against a finding that a 10 percent disability evaluation is justified. Given the Veteran's complaints associated with employment, the Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). See Barringer v. Peake, 22 Vet. App. 242 (2008). The record reflects that the Veteran has not required frequent hospitalization for the disability, and that the manifestations of the disability are not in excess of those contemplated by the assigned rating. Further, although he experiences occupational impairment, there is no indication in the record that the average industrial impairment from the disability would be in excess of that contemplated by the assigned ratings. The Court has held that, "if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required." Thun v. Peake, 22 Vet. App. 111, 115 (2008). Therefore, the Board has concluded that referral of this case for extra-schedular consideration is not in order. Finally, in light of the holding in Fenderson, supra, the Board has considered whether the Veteran is entitled to a "staged" rating for his service-connected hypertension, as the Court indicated can be done in this type of case. Based upon the record, we find that at no time since April 15, 2006, the date on which his service connection for hypertension was effective, has the disability on appeal been more disabling than as currently rated under the present decision of the Board. The preponderance of the evidence is against the claim, and there is no reasonable doubt to be resolved. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. B. Service Connection for PTSD In order for service connection to be awarded for PTSD, three elements must be present: (1) a current medical diagnosis of PTSD; (2) medical evidence of a causal nexus between current symptomatology and a claimed in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor(s) actually occurred. 38 C.F.R. § 3.304(f) (2009); Cohen v. Brown, 10 Vet. App 128 (1997). With respect to the second element, if the evidence shows that the veteran did not serve in combat with enemy forces during service, or if there is a determination that the veteran engaged in combat but the claimed stressor is not related to such combat, there must be independent evidence to corroborate the veteran's statement as to the occurrence of the claimed stressor. Doran v. Brown, 6 Vet. App. 283, 289 (1994). The veteran's testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor. See Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). The Veteran's service treatment records (STRs) do not show any complaints, treatment or diagnoses related to PTSD. In a June 2007 statement the Veteran wrote that in March 2005 a vehicle in which he was a passenger flipped over, killing his noncommissioned officer on the spot. The Veteran underwent a VA examination for PTSD in January 2008, at which he said that he was not undergoing any mental health treatment, including counseling or medication. He said that he began having emotional problems in 2005 and that he currently has difficulty sleeping. He has initial and middle insomnia and nightmares about two times per week about automobile accidents he witnessed in service. He has intrusive thoughts about the automobile accidents four to five times per week; he denied any psychotic symptoms or ever being suicidal or homicidal. The Veteran said that during his active service he was a combat engineer, and was never deployed. During a training procedure he saw a badly burned body of a peer who had been in a tank accident and survived. The Veteran said that he came upon the aftermath of an automobile accident on a highway in which children were killed. He also said that he was in charge of training soldiers who eventually went to Iraq. The examiner noted that the Veteran's post-military trauma included being aware of friends who had died in Iraq. The Veteran also reported anxiety, panic attacks, insomnia, increased appetite, nightmares, head pain, racing thoughts, and anger control problems that were expressed at work. He denied auditory or visual hallucinations or delusions. The Veteran said that he had been working at an automobile dealership and had been honored as the salesman of the year. He denied having any specific functional impairment related to his work. He said he had a good relationship with his family and his fiancee, although his patience was short and he was a bit impulsive, which he felt was related to his military service. He indicated that he had no real fun in his life, although the examiner noted that the Veteran seemed to have a pleasant relationship with his fiancee. The examiner observed that the Veteran had normal affect and mental functioning, and there were no signs or symptoms of mental distress. Thought processes were logical, coherent and relevant. He was also noted to be articulate, verbal, well dressed, well groomed, and cooperative. He had good social skills and was well oriented to time, place, person, and situation. His affect was spontaneous and his reasoning and fund of information were good. The Veteran exhibited no psychomotor slowing or agitation, and his verbal comprehension, concentration and memory were good. His sensorium was clear, and he denied any head trauma, seizures or strokes. The examiner opined that the Veteran did not have any serious problem behaviors, or functional impairment in occupational or social settings. He felt that the Veteran "certainly" did not fit the criteria for a diagnosis of PTSD, although he had been exposed to some traumatic scenes and scenarios. The examiner noted that the Veteran did not have any serious symptoms or functional impairment. The Veteran's score on the Minnesota Multiphasic Personality Inventory - 2 was indicative of a separate mood disorder or the potential for a mood disorder and the possible emergence of a bipolar disorder. The PTSD PK scale was noted to not be significant. The examiner diagnosed the Veteran with mood disorder, NOS (not otherwise specified), and did not feel that it was related to military service. In February 2008 the VA examiner reviewed the claims file and wrote that the diagnosis and conclusions from the January 2008 examination were unchanged. We recognize the sincerity of the arguments advanced by the Veteran that he has PTSD that is service connected. However, the resolution of issues that involve medical knowledge, such as the diagnosis of a disability and the determination of medical etiology, requires professional evidence. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). It is true that the Veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau, supra; Buchanan, supra (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition, the lay person is reporting a contemporaneous medical diagnosis, or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, supra. However, PTSD requires specialized training for a determination as to diagnosis and causation, and is therefore not susceptible of lay opinions on etiology. While the Board expresses its appreciation for the Veteran's service, absent proof of the existence of the disability being claimed, there can be no valid claim. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Degmitech v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). The Board recognizes that the Court of Appeals for Veterans Claims has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, where, as here, the overall evidence of record fails to support a diagnosis of the claimed PTSD, that holding would not be applicable. Based upon the evidentiary record, service connection for PTSD must be denied. The Board need not evaluate the other elements necessary for service connection for PTSD, since the absence of one requirement means an award of service connection is not possible. Because the evidence preponderates against the claim of service connection for PTSD, the benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. C. Service Connection for a Right Arm Scar, Skin Rash, Right Inguinal Hernia, Migraine Headaches, Residuals of a Left Knee Injury, and Low Back Disorder The STRs show that in January 2004 the Veteran complained of a rash on his arms that was spreading on his sides. He was noted to have ringworm. At followup treatment in March 2004, the Veteran was diagnosed with tinea corporis and tinea versicolor. It had been unresponsive to multiple prescriptions. In June 2004 he complained of a rash that had persisted for a week. He had circular, scaly lesions on his left chin and itching and burning on his back. The STRs do not indicate further ongoing treatment for a skin rash. In November 2005 the Veteran had the symptoms of an inguinal hernia. However, a CT scan showed no evidence of an inguinal hernia. The assessment from treatment was atrophy of the inguinal muscle group. At January 2006 treatment he complained of continued right lower quadrant abdominal pain and of a bulge in that area. An ultrasound of the abdomen showed no abnormalities, including no evidence of a mass or a hernia. At March 2006 treatment the Veteran continued to complain of abdominal pain, but he was not diagnosed with a hernia. The STRs do not show any complaints, treatment, or diagnoses related to a right arm scar, migraine headaches, the left knee, or lower back. VA post-service treatment records show that in September 2006 the Veteran underwent a left a left anterior cruciate ligament reconstruction with bone-tendon-bone graft after sustaining an injury while playing soccer. At November 2006 treatment it was noted that the Veteran had some initial pain, numbing, and tingling, and that his condition was improved. There was still some tickling of the lateral aspect of the knee, and at times he felt as if he might be buckling forward. The knee was described in the treatment notes as being "basically non-painful." The treatment notes indicate that the Veteran wanted his treating providers to state in a note that he had a previous injury in the military. The physician assistant noted that there was no documentation supporting this, although the Veteran stated that after injuring the same knee while in the military he was on a limited-duty profile for three weeks. A December 2007 VA treatment note indicates that the Veteran had continued chronic knee pain. The Veteran's service records which have been associated with the claims file do not indicate that he was placed on a profile due to his left knee. At October 2007 VA treatment the Veteran complained of shin splints, numbness of the fingertips in the right hand post laceration, and of a hernia. At the Veteran's January 2008 examination for hypertension he reported that he had a severe headache while in his barracks in April 2005. He said he went to sick call and was given ibuprofen. Since then he reported having headaches on a monthly basis that would last for about 30 minutes and were relieved with medication. He described the headaches as causing sharp pain, with no nausea or vomiting. Aggravating factors were spending long periods of time in the sun or a lack of rest or sleep. He had no problems with noise or light, and he rated the severity of the pain as an eight out of ten. He said he was still having headaches that occurred one to two months apart, with a severity of five out of ten. The headaches responded well to NSAID (non-steriodal anti- inflammatory drug) medications, and he had not seen a doctor for them. The Veteran felt that the main trigger was stress from his job. On examination, he was normal from a neurological standpoint. The examiner diagnosed headaches, tension, not migraine. The examiner noted in regard to a skin rash that the Veteran did not presently have a residual rash, and no scarring was noted. In addition, the examiner did not note a scar in the Veteran's right arm. In regards to a hernia, the Veteran said that he still got pain when running, although he had not ran since his knee surgery. On examination he did not have a hernia in the inguinal region. At a VA joint examination in January 2008 the Veteran reported that he was still experiencing left knee pain, and he wore a brace when doing heavy activities. On examination the left knee had a full range of motion and positive patellofemoral crepitus. There was no ulceration or breakdown, effusion, or instability to varus/vulgus stress, and Lachman's sign was negative. However, there was some laxity when the knee was flexed to 90 degrees, causing some slight rotational instability due to the slight laxity in the patellar tendon. The examiner diagnosed left knee anterior cruciate ligament reconstruction with stability and some laxity of the patellar tendon, allowing slight rotational instability of the knee. The Veteran also underwent a VA spine examination in January 2008, at which he reported increasing lower back pain with everyday activities and with running. The pain was throbbing, sharp and aching, and there were no flare-ups, incoordination, fatigue, weakness, or lack of endurance, numbness, weakness, or incontinence. The Veteran did not use any braces or assistive devices, he was unaffected by his back in his occupation, and had not had any incapacitating episodes in the prior 12 months. The examiner observed that he had a normal gait. On examination, the Veteran was tender in the left paraspinous muscles with increased muscle tone but no spasm. He had a full range of motion in the lumbar spine with forward flexion of 0 to 90 degrees, extension of 0 to 30 degrees, and right/left lateral rotation and flexion of 0 to 30 degrees with pain only on right lateral rotation and left lateral rotation. Reflexes were somewhat diminished in the knee and ankle jerks bilaterally. Straight leg raising was negative to 90 degrees in the sitting position bilaterally. There was full motor strength in all muscle groups of the lower extremities bilaterally, and sensation was intact to sharp/dull in all dermatomes. The Veteran had no additional limitations following repetitive use, other than increased pain. He had no flare-ups or effect of incoordination, fatigue, weakness, or lack of endurance on his spine function. The examiner diagnosed the Veteran with myofascial lumbar syndrome. In February 2008 the claims file was reviewed in relation to the hand, thumbs, and fingers examination, the hypertension examination, and the joints examination. There were no changes in the diagnoses. Upon review of the evidence, the Board finds that service connection is not warranted for a right arm scar, skin rash, right inguinal hernia, migraine headaches, residuals of a left knee injury, and low back disorder. The record does not show that the Veteran has had a right arm scar, right inguinal hernia, or migraine headaches at any point or that he has had a skin rash since his active service. While he was diagnosed with tension headaches at a VA examination, he has not been found to have migraine headaches. Absent proof of the existence of the disability being claimed, there can be no valid claim. See Gilpin, supra; Degmitech, supra; Brammer, supra; Rabideau, supra. The Board recognizes that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain, supra. However, where, as here, the overall evidence of record fails to support a diagnosis of the claimed disorders, that holding does not apply. While the record shows that the Veteran has current low back and left knee disorders, the STRs do not show any complaints, treatment or diagnoses related to these disorders or that arthritis related to his lower back or left knee was manifested within a year of active service. There is no indication from the record that these disorders are related to the Veteran's active service. Furthermore, the record shows that the Veteran injured his left knee playing soccer after his active service. Despite the sincerity of the arguments advanced by the Veteran that his right arm scar, skin rash, right inguinal hernia, migraine headaches, residuals of a left knee injury, and low back disorder are service connected, the resolution of issues that involve medical knowledge, such as the diagnosis of a disability and the determination of medical etiology, requires professional evidence. See Espiritu, supra. His lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau, supra; Buchanan, supra (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition, the lay person is reporting a contemporaneous medical diagnosis, or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, supra. However, a right arm scar, skin rash, right inguinal hernia, migraine headaches, residuals of a left knee injury, and low back disorder require specialized training for a determination as to diagnosis and causation, and are therefore not susceptible of lay opinions on etiology. Because the evidence preponderates against the claim of service connection for right arm scar, skin rash, right inguinal hernia, migraine headaches, residuals of a left knee injury, and low back disorder, the benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. D. Service Connection for the Residuals of an Injury to the Fingers of the Right Hand The Veteran's STRs show that in November 2003 he lacerated the third and fourth digits of a hand. He was diagnosed with a skin avulsion on the distal tips of the third and fourth digits. The STRs do not show follow up treatment related to the fingers of the right hand. In January 2008 the Veteran underwent a VA examination for the hand, thumbs, and fingers. It was noted in his history that he suffered lacerations to the distal tips of the middle and ring fingers while stationed in Iraq from the heating fan in a Humvee. As a preliminary matter, the Board notes that the Veteran's DD Form 214 indicates that he did not have any foreign service. At time of the examination, he complained of numbness in the fingertips but no pain. On examination he had a full range of motion on the fingers of the right hand without pain. There was some decreased sensation to light touch in the distal fingertips, and the nails appeared normal. The Veteran could touch, probe, write, twist, pull, push and grasp with his right hand, and he could oppose his thumb to his fingertips and bring his fingertips to the palmar crease. The examiner diagnosed lacerations to the tips of the right middle and ring fingers, with residual numbness of the tips. Having weighed the evidence both in support and against the claim of service connection for the residuals of an injury to the fingers of the right hand, the Board concludes that the weight of the evidence is at least in relative balance on the merits of the Veteran's claim. The Veteran is qualified to report numbness in his fingertips, and the VA examiner diagnosed the Veteran with residual numbness from the in- service lacerations to the tips of the right middle and ring fingers. See Davidson, supra. In view of the foregoing, the Board finds that service connection is warranted for the residuals of an injury to the fingers of the right hand. ORDER Entitlement to an initial compensable evaluation for hypertension is denied. Service connection for PTSD is denied. Service connection for a right arm scar is denied. [Continued on next page] Service connection for a skin rash is denied. Service connection for a right inguinal hernia is denied. Service connection for migraine headaches is denied. Service connection for residuals of a left knee injury is denied. Service connection for a low back disorder is denied. Service connection for the residuals of an injury to the fingers of the right hand is granted. REMAND The STRs show that the Veteran was treated for complaints of shin splints in January 2005. He rated the pain as a seven out of ten when running, and had felt pain on the bone s of his shins for two months. The STRs do not indicate follow up treatment related to shin splints. He was treated for his left shoulder in February 2005 after someone fell on top of him. He was diagnosed with an acute strain. At subsequent treatment the Veteran was noted to have a possible left shoulder separation. The STRs do not show further treatment related to the left shoulder. At the VA joint examination in January 2008 the Veteran reported that he still had pain in his shins when he ran. Stretching provided some relief. He also reported occasional stinging in his left shoulder, but it was described as "nothing of consequence." There were no periods of flare- ups in any of his joints. On examination, the shins were tender along the anterior tibialis insertions bilaterally proximately, and he had some pain with dorsiflexion of his ankles. The examiner diagnosed the Veteran with bilateral shin splints, ongoing, milder in quality due to a restriction of activities compared with when in the military. In regard to his left shoulder, the examiner opined that the Veteran had "minimal if any disability." The United States Court of Appeals for Veterans Claims in Barr v. Nicholson, 21 Vet. App. 303, 311 (2007), found that once VA undertakes the effort to provide an examination, it must provide an adequate one. In the present case, the January 2008 VA examiner did not offer a nexus opinion, i.e., as to whether the Veteran's current shin splints are related to the shin splints that the Veteran had during his active service. Furthermore, the it is not clear from the examiner's diagnosis whether the Veteran has any current residuals of a left shoulder separation. Therefore, the Board finds that medical opinions must be obtained before the claim for service connection for these disorders can be decided on the merits. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran provide sufficient information, and, if necessary, authorization, to enable the RO to obtain any additional evidence, not already of record, which pertains to the claim for service connection for bilateral shin splints and residuals of a left shoulder separation. Invite the Veteran to submit all pertinent evidence in his possession, and explain the types of evidence that it is his ultimate responsibility to submit. 2. Request an examination report addendum from the examiner who conducted the January 2008 examination. The claims file, to include a copy of this Remand, must be made available to the examiner. If the January 2008 examiner is not available, the RO should request review of the Veteran's claims file by another provider. In the report addendum, a medical opinion should be provided as to: a. Whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that the Veteran's current shin splints were caused directly by or arose during his active military service or are otherwise causally or etiologically related to service, or whether such an incurrence, or causal or etiological relationship, is unlikely (i.e., less than a 50 percent probability), with the rationale for any such conclusion set out in the report. If the examiner cannot state an opinion without resorting to mere speculation, he should state why this is so. b. Whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that the Veteran's has residuals of a left shoulder separation that were caused directly by or arose during his active military service or are otherwise causally or etiologically related to service, or whether such an incurrence, or causal or etiological relationship, is unlikely (i.e., less than a 50 percent probability), with the rationale for any such conclusion set out in the report. If the examiner cannot state an opinion without resorting to mere speculation, he should state why this is so. c. Note: As used above, the term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. 3. Thereafter, the RO should readjudicate the Veteran's claim for service connection for bilateral shin splints and the residuals of a left shoulder separation. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided with an SSOC. The appellant has the right to submit additional evidence and argument on the matter or 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. 2009). ___________________________ ANDREW J. MULLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs