Citation Nr: 1018965 Decision Date: 05/24/10 Archive Date: 06/04/10 DOCKET NO. 06-29 023 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for pingueculae of the bilateral eyes. 2. Entitlement to service connection for a psychiatric disorder, to include major depressive disorder (MDD). 3. Entitlement to service connection for insomnia. 4. Entitlement to service connection for bilateral hearing loss, to include bilateral ear disabilities. 5. Entitlement to service connection for irritable bowel syndrome (IBS), to include as secondary to PTSD. 6. Entitlement to service connection for hemorrhoids. 7. Entitlement to service connection for bilateral eye refractive error. 8. Entitlement to service connection for posttraumatic stress disorder (PTSD). 9. Entitlement to service connection for headaches. 10. Entitlement to service connection for bilateral tinnitus. 11. Entitlement to service connection for gastroesophageal reflux disease (GERD). 12. Entitlement to an initial disability rating in excess of 10 percent for calcaneal spurs of the left heel. 13. Entitlement to an initial disability rating in excess of 10 percent for calcaneal spurs of the right heel. 14. Entitlement to an initial disability rating in excess of 10 percent for a left hip disability, to include enthesopathy and trochanteric bursitis. 15. Entitlement to an initial disability rating in excess of 10 percent for a right hip disability, to include enthesopathy and trochanteric bursitis. 16. Entitlement to an initial compensable disability rating for left knee patellofemoral syndrome. 17. Entitlement to an initial compensable disability rating for right knee patellofemoral syndrome. 18. Entitlement to an initial compensable disability rating for chronic cystitis (claimed as urinary tract infections). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K.A. Kennerly, Counsel INTRODUCTION The appellant served in the United States Army Reserves from March 1977 to February 2003. The appellant served on active duty in the Persian Gulf from February 2003 to May 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2005 rating decision of the San Juan, Puerto Rico, Regional Office (RO) of the Department of Veterans Affairs (VA). The appellant filed her original claims in October 2004. In August 2005, the RO granted entitlement to service connection for the following disabilities: left heel calcaneal spurs [assigning a 10 percent disability rating]; right heel calcaneal spurs [assigning a 10 percent disability rating]; a left hip disability, to include enthesopathy and trochanteric bursitis [assigning a noncompensable disability rating]; a right hip disability, to include enthesopathy and trochanteric bursitis [assigning a noncompensable disability rating]; left knee patellofemoral syndrome [assigning a noncompensable disability rating]; right knee patellofemoral syndrome [assigning a noncompensable disability rating]; and chronic cystitis (claimed as urinary tract infections) [assigning a noncompensable disability rating]. The August 2005 rating decision also denied entitlement to service connection for the following disabilities: headaches; bilateral tinnitus; bilateral pingueculae; a psychiatric disorder, to include MDD; PTSD; IBS, to include as secondary to PTSD; bilateral hearing loss, to include bilateral ear disabilities; hemorrhoids; a sleep disorder; GERD; and bilateral eye refractive error. In November 2005, the appellant submitted a Notice of Disagreement with the determinations made for all of the aforementioned claims. A Statement of the Case was issued in July 2006. At the time, the RO increased the disability ratings for the appellant's bilateral hip disabilities from noncompensable to 10 percent disabling each. A July 2006 rating decision implemented this action. The appellant perfected her appeal in September 2006. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2009). The appellant has been accorded the opportunity to present evidence and argument in support of her claims. In her September 2006 Substantive Appeal [VA Form 9] she declined the option of testifying at a personal hearing. The issues of entitlement to service connection for bilateral plantar fasciitis, a bilateral ankle disability, to include as secondary to service-connected disabilities, and TDIU have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issues of entitlement to service connection for headaches, tinnitus and GERD as well as the issues of entitlement to initial increased disability ratings for bilateral heel calcaneal spurs, bilateral hip disabilities, bilateral patellofemoral knee syndrome, and chronic cystitis 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. The appellant will be notified if further action on her part is required. FINDINGS OF FACT 1. The preponderance of the evidence supports a finding that the appellant currently suffers from pingueculae of the bilateral eyes that is the result of a disease or injury in service. 2. The preponderance of the evidence supports a finding that the appellant currently suffers from a psychiatric disorder, to include MDD, which is the result of a disease or injury in service. 3. The preponderance of the evidence supports a finding that the appellant currently suffers from insomnia that is the result of a disease or injury in service. 4. The preponderance of the evidence is against a finding that the appellant currently suffers from bilateral hearing loss for VA purposes, that is the result of a disease or injury in service. 5. The appellant does not have a current diagnosis of IBS. 6. The appellant does not have a current diagnosis of hemorrhoids. 7. The appellant's vision impairment consists of simple refractive error, correctable to normal visual acuity. 8. The preponderance of the evidence establishes that the appellant does not have a diagnosis of PTSD in accordance with the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)) which is based on a verified stressor. CONCLUSIONS OF LAW 1. Pingueculae of the bilateral eyes was incurred during active duty service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303, 3.304 (2009). 2. A psychiatric disorder, to include MDD, was incurred during active duty service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303, 3.304 (2009). 3. Insomnia was incurred during active duty service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303, 3.304 (2009). 4. Bilateral hearing loss was not incurred in or aggravated by active duty service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303, 3.304 (2009). 5. IBS was not incurred in or aggravated by active duty service, nor is it the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303, 3.304, 3.310 (2009). 6. Hemorrhoids were not incurred in or aggravated by active duty service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303, 3.304 (2009). 7. Vision loss due to refractive error is precluded by the regulations. 38 C.F.R. § 3.303(c)(2009). 8. PTSD was not incurred in or aggravated by active duty service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. The Veterans Claims Assistance Act of 2000 (VCAA) As to the claims of entitlement to service connection for pingueculae of the bilateral eyes, a psychiatric disorder and insomnia, these claims have been granted, as discussed below. As such, the Board finds that any error related to the VCAA on these claims is moot. See 38 U.S.C. §§ 5103, 5103A (West 2002 & Supp. 2009); 38 C.F.R. § 3.159 (2009); Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With respect to the appellant's remaining claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2009). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claims. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2009); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (the Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claims; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Prior to initial adjudication of the appellant's claims, a letter dated in November 2004 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2009); Quartuccio, at 187. Notice letters dated in March 2006 and July 2006 informed the appellant of how VA determines the appropriate disability rating or effective date to be assigned when a claim is granted, consistent with the holding in Dingess/Hartman v. Nicholson. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (2009) (harmless error). In view of the foregoing, the Board finds that the appellant was notified and aware of the evidence needed to substantiate her claims, as well as the avenues through which she might obtain such evidence, and of the allocation of responsibilities between herself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. The Board also concludes VA's duty to assist has been satisfied. The appellant's service treatment records and VA medical records are in the file. The appellant has at no time referenced outstanding records that she wanted VA to obtain or that she felt were relevant to the claims. In fact, the appellant specifically stated that she only received medical treatment through VA. See Appellant's Statements, February 8, 2006 & August 18, 2006. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The record indicates that the appellant participated in two VA examinations and the results from those examinations have been included in the claims file for review. The examinations involved a review of the claims file, a thorough examination of the appellant, and opinions that were supported by sufficient rationale. Therefore, the Board finds that the examinations are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claims). Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the appellant's claims. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. The Merits of the Claims Pingueculae, Psychiatric Disorder & Insomnia The appellant contends that she currently suffers from pingueculae of the bilateral eyes, a psychiatric disorder and insomnia that are the result of her time in active duty service. The Board concurs. Relevant Law and Regulations Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110, 1131 (West 2002). For the showing of 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. See 38 C.F.R. § 3.303(b) (2009). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2009). In order to establish service connection for the claimed disorder, there must be (1) 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) a causal connection between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Pursuant to 38 U.S.C.A. § 1154(b) (West 2002), with respect to combat veterans, "[VA] shall accept as sufficient proof of service-connection . . . satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions and hardships of such service . . . Service connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary." See also 38 C.F.R. § 3.304(d) (2009). However, the Court has further held that 38 U.S.C.A. § 1154(b) can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to the current disorder. See Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996). Section 1154(b) does not establish service connection for a combat veteran; it aids her by relaxing the adjudicative evidentiary requirements for determining what happened in service. A veteran must still generally establish her claim by competent medical evidence tending to show a current disability and a nexus between that disability and those service events. See Gregory v. Brown, 8 Vet. App. 563, 567 (1996). In Kessel v. West, 13 Vet. App. 9 (1999), the Court affirmed that the 38 U.S.C.A. § 1154(b) presumption only relates to the question of service incurrence, it does not relate to questions of whether a veteran has a current disability or whether there was a nexus between the in- service event and the current disability. Analysis Initially, the Board notes that the appellant has been diagnosed with bilateral pingueculae, depression, and insomnia. See VA Eye Examination Report, December 23, 2004; VA PTSD Examination Report, December 20, 2004; and VA Persian Gulf War Examination Report, November 9, 2004. Thus, element (1) under Hickson, current disability, has been satisfied. Concerning Hickson element (2), in-service disease or injury, the Board notes that the appellant's service treatment records do not reveal any complaints of eye problems, psychiatric disorders or sleep difficulties. However, the appellant's representative argues that despite the lack of any award that is indicative of combat, the appellant was stationed in Iraq during her active duty status and was in a combat zone, receiving designated danger pay. See Appellant's Brief, September 28, 2009. The Board agrees. Despite the fact that the appellant did not receive an award designated for combat, her duty station location is sufficient to award the combat presumption set forth in 38 U.S.C.A. § 1154(b) (West 2002). Accordingly, the appellant's claimed diseases or injuries in service are presumed. With respect to crucial Hickson element (3), medical nexus, the Board is aware of the December 2004 VA eye examination report. Therein, the VA examiner stated that it was at least as likely as not that the appellant's pingueculae were caused by or the result of sand storms and increased ambient temperatures in Iraq. See VA Eye Examination Report, December 23, 2004. There is no medical evidence of record to the contrary. With regard to the appellant's claim for a psychiatric disorder, VA Medical Center (VAMC) treatment records as well as the December 2004 VA PTSD examination diagnosed her with MDD. Though the VA examination indicated that the appellant suffered from a single episode of MDD during her time in service, the November 2004 Persian Gulf War examination report diagnosed the appellant with anxiety reaction and nervousness, secondary to her Gulf War experiences. See VAMC Persian Gulf War Examination Report, November 9, 2004. This examination report also diagnosed the appellant with insomnia secondary to her Gulf War experiences. Id. Affording the appellant the full benefit of the doubt, in addition to the existence of her continuing treatment for depression and insomnia (see 38 C.F.R. § 3.303(b) (2009)), the Board finds that the medical evidence of record is in equipoise and the appellant is entitled to service connection for a psychiatric disorder and insomnia. The evidence in this case is approximately balanced regarding the question of whether the appellant currently suffers from bilateral pingueculae, a psychiatric disorder and insomnia that are the result of her time on active duty. Therefore, the benefit-of-the-doubt will be conferred in her favor and her claims for service connection are granted, subject to the controlling laws and regulations, which govern awards of VA compensation. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.400 (2009); see also Gilbert v. Derwinksi, 1 Vet. App. 49 (1990). Bilateral Hearing Loss & Ear Disabilities The appellant contends that she currently suffers from bilateral hearing loss and ear disabilities that are the result of her time in active duty service in a combat zone. The Board disagrees. Where a veteran had active and continuous military service for 90 days or more during a period of war, and sensorineural hearing loss (as an organic disease of the nervous system) becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in, or aggravated by, service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309 (2009). As noted above, in the case of any veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service, even though there is no official record of such incurrence or aggravation. Every reasonable doubt shall be resolved in favor of the veteran. See 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(d) (2009). VA has specifically defined what is meant by a "disability" for the purposes of service connection. See 38 C.F.R. § 3.385 (2009). ("[I]mpaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent."). At the outset, the Board notes that the appellant does not have a current diagnosis of bilateral hearing loss for VA purposes or any other ear disability. During the December 2004 audiological examination, the appellant's audiometric findings were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 15 15 20 LEFT 15 15 15 15 20 See VA Audiological Examination Report, December 30, 2004. The VA examiner commented that there was normal compliance of both tympanic membranes with acoustic reflexes present at expected levels and no acoustic reflex decay. The appellant was diagnosed with hearing within normal limits from 500 Hertz (Hz) to 4000 Hz, normal middle ear function and word recognition scores within normal limits. Id. Further, the appellant participated in a VA audiological consult in January 2006. At that time, her audiometric findings were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 15 15 15 15 LEFT 15 15 15 15 20 See VA Audiological Consult, January 11. 2006. In sum, there is no evidence of sensorineural hearing loss within one year of the appellant's service separation. See 38 C.F.R. §§ 3.303, 3.307, 3.309 (2009); Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Further, though the Board is aware that the appellant complained of ear aches and ear pain in service, she does not currently demonstrate bilateral hearing loss for VA purposes. See 38 C.F.R. § 3.385 (2009). The only evidence in support of the appellant's claim consists of her own lay statements alleging that she suffers from hearing loss and ear disabilities that are related to service. The Board acknowledges that the appellant is competent to give evidence about what she experiences; for example, she is competent to discuss her trouble hearing. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). She is not, however, competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because she does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). In order to be considered for service connection, a claimant must first have a disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). In the absence of a diagnosis of bilateral hearing loss for VA purposes or any other ear disability, service connection may not be granted. See also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. In this case, for the reasons and bases discussed above, a reasonable doubt does not exist regarding the appellant's claim. There is not an approximate balance of evidence. IBS & Hemorrhoids The appellant contends that she currently suffers from IBS, to include as secondary to PTSD, and hemorrhoids, as a result of her time in active duty service. The Board disagrees. Review of the medical evidence of record does not establish that the appellant currently suffers from either IBS or hemorrhoids. While the Board is aware that the appellant had once complained of hemorrhoids in service in December 2003, this was noted to be a small external hemorrhoid that was asymptomatic and associated with an episode of constipation. In July 2006, during a VA routine physical examination, examination of the appellant's rectum revealed no external anal lesions and no internal or external hemorrhoids. See VAMC Treatment Record, July 17, 2006. At no time has the appellant been diagnosed with IBS. See VA Treatment Records, generally. The only evidence in support of the appellant's claims consists of her own lay statements alleging that she suffers from IBS and hemorrhoids that are related to service. The Board acknowledges that the appellant is competent to give evidence about what she experiences. See, e.g., Layno, supra. She is not, however, competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because she does not have the requisite medical knowledge or training. See Rucker, supra. In order to be considered for service connection, a claimant must first have a disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). In the absence of diagnosed IBS and hemorrhoids, service connection may not be granted. See also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). As the appellant has failed to establish that she currently suffers from IBS, the Board need to address her contention that IBS is secondary to PTSD. Accordingly, the Board concludes that the preponderance of the evidence is against the claims for service connection, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. In this case, for the reasons and bases discussed above, a reasonable doubt does not exist regarding the appellant's claims. There is not an approximate balance of evidence. Bilateral Refractive Error The appellant contends that she currently suffers from bilateral refractive error as a result of her time in active duty service. The Board disagrees. For purposes of entitlement to benefits, the law provides that refractive errors of the eyes are congenital or developmental defects and are not a disease or injury within the meaning of applicable legislation. In the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes, including myopia, presbyopia, and astigmatism, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. See 38 C.F.R. §§ 3.303(c), 4.9 (2009). Thus, VA regulations specifically prohibit service connection for refractive errors of the eyes unless such defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90 (July 18, 1990) (cited at 55 Fed. Reg. 45,711) (Oct. 30, 1990). The appellant's Army Retention Examination indicated that her eyes were normal, but that she had refractive errors correctable by lenses. See Service Treatment Record, February 26, 2005. The appellant was also afforded VA eye and general examinations in December 2004 to determine if she suffered from an eye disability that was causally related to a traumatic event in service. The diagnoses were refractive error corrected with eyeglasses. See VA Examination Reports; December 20, 2004 & December 23, 2004. Based on the above, the Board must conclude that the appellant's refractive error is of a congenital nature. The Board acknowledges that the appellant is competent to give evidence about what she experiences; for example she is competent to discuss her vision problems. See, e.g., Layno, supra. She is not, however, competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because she does not have the requisite medical knowledge or training. See Rucker, supra. The appellant's bilateral refractive error is not a disorder capable of service connection, and the claim must be denied. See Sabonis v. Brown, 6 Vet. App. 426 (1994). In light of the aforementioned, the Board concludes that service connection for bilateral refractive error must be denied. As reflected by the discussion above, the preponderance of the evidence is against the appellant's claim. As such, the benefit-of-the-doubt rule does not apply. See 38 U.S.C.A. § 5107(b) (West 2002). PTSD The appellant contends that she currently suffers from PTSD that is the result of her time in active duty service. Specifically, she alleges that she was assaulted during a visit to a water park while on liberty in Iraq. Service connection for PTSD requires medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (2009). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a), which simply mandates that, for VA purposes, all mental disorder diagnoses must conform to the fourth edition of the DSM-IV. See 38 C.F.R. § 3.304(f) (2009). As noted above, during her time in active duty service in Iraq, the appellant served in an imminent danger combat zone and received danger pay. As such, she is afforded the presumption set forth under 38 U.S.C.A. § 1154(b). The appellant reported that while on liberty, she and a group of other service members went to a water park. The appellant was the last person at the top of the water slide platform, when a water park employee touched her breast. In order to establish service connection for PTSD, there must also be evidence of a valid medical diagnosis of PTSD under the DSM-IV, as well as link between current PTSD and the in- service stressor. See 38 C.F.R. § 3.304(f) (2009). The appellant was afforded a VA PTSD examination in December 2004. At that time, the appellant complained of feeling sad and depressed, with irritability and loss of interest in the activities of daily life. She was unable to concentrate and suffered from anxiety and tension. She did not complain of nightmares, intrusive thoughts or recurrent memories. After reviewing the appellant's claims file, the VA examiner concluded that the appellant did not meet the DSM-IV criteria for a diagnosis of PTSD. The VA examiner stated that the appellant was not able to specify and describe in detail a severe and horribly traumatic event or incident experience while in service. The VA examiner opined that the situation she described was unpleasant, but not traumatic. The appellant was not ever in a combat situation with the enemy. She was not observed to become anxious, distressed or depressed when she described her experiences in Iraq. She did not report feelings of intense fear, helplessness or horror at the time when she experienced the event in Iraq. Further, there was no evidence in the appellant's clinical picture of avoidance of a stimuli associated with the trauma. Her memories about Iraq were not intrusive, persistent and distressing thoughts, interfering with daily function. Since the VA examiner could not identify signs and symptoms of PTSD and definite extreme traumatic stressors, a link was not established between the reported stressor and the appellant's mental disorder. See VA PTSD Examination Report, December 20, 2004. Though the Board is aware of the September 2004 VA treatment note that diagnosed the appellant with PTSD, it is clear that this diagnosis was provided strictly on the basis of the appellant's provided history. Further, the physician did not provide a basis of the diagnosis provided. Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Accordingly, the Board does not find this opinion to be persuasive. Rather, the VA PTSD examination is the most credible, as the VA examiner provided a thorough rationale for the conclusion that the appellant did not meet the DSM-IV criteria for a diagnosis of PTSD. The only remaining evidence in support of the appellant's claim consists of her lay statements alleging that she currently suffers from PTSD. The Board acknowledges that the appellant is competent to give evidence about what she experiences; for example, she is competent to discuss her symptoms. See, e.g., Layno, supra. She is not, however, competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because she does not have the requisite medical knowledge or training. See Rucker, supra. Based on the above, the Board finds that the appellant does not have a sufficiently supported diagnosis of PTSD. The Board acknowledges that the appellant has been diagnosed with a psychiatric disorder, to include depression and anxiety, for which she has been granted service connection. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for PTSD, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. In this case, for the reasons and bases discussed above, a reasonable doubt does not exist regarding the appellant's claim that she has a current diagnosis of PTSD. There is not an approximate balance of evidence. ORDER Entitlement to service connection for pingueculae of the bilateral eyes is granted. Entitlement to service connection for a psychiatric disorder, to include MDD, is granted. Entitlement to service connection for insomnia is granted. Entitlement to service connection for bilateral hearing loss, to include bilateral ear disabilities, is denied. Entitlement to service connection for IBS, to include as secondary to PTSD, is denied. Entitlement to service connection for hemorrhoids is denied. Entitlement to service connection for bilateral eye refractive error is denied. Entitlement to service connection for PTSD is denied. REMAND After a thorough review of the appellant's claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of the appellant's claims of entitlement to service connection for headaches, tinnitus and GERD as well as the issues of entitlement to initial increased disability ratings for bilateral heel calcaneal spurs, bilateral hip disabilities, bilateral patellofemoral knee syndrome, and chronic cystitis. As noted above, in order to establish service connection for the claimed disorder, there must be (1) 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) a causal connection between the claimed in-service disease or injury and the current disability. See Hickson, supra; see also Shedden, supra. The duty to assist includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. With regard to the issue of entitlement to service connection for headaches, the Board notes that the appellant has been diagnosed with headaches. See VA Eye Examination Report, December 23, 2004. Review of the appellant's service treatment records indicates that she reported experiencing headaches. See Service Treatment Records, March 25, 2004 & April 2, 2004. Though the appellant was afforded VA examinations in December 2004, these examinations did not provide a statement as to whether the appellant's current headaches were the result of her time in active duty service. Accordingly, as there is insufficient evidence to decide this claim, the appellant must be afforded a new VA examination to determine the nature and etiology of her headaches. As noted above, the Board has determined that the appellant is afforded the presumption set forth under 38 U.S.C.A. § 1154(b) (West 2002 & Supp. 2009). Accordingly, exposure to acoustic trauma in service is conceded. However, despite this concession, a medical nexus is still required to determine whether the appellant's currently alleged bilateral tinnitus is the result of her active duty service. Though the appellant has a current diagnosis of bilateral tinnitus (see VA Audiological Examination, December 30, 2004; VAMC Audiological Consult, January 11, 2006), the December 2004 VA audiological examination failed to provide a nexus statement as to whether this condition is the result of her time in active duty service. As such, the appellant must be afforded a new VA audiological examination to determine the nature and etiology of her current bilateral tinnitus. With respect to the appellant's claim of entitlement to service connection for GERD, again, she received a diagnosis of GERD during the December 2004 VA general examination, but the VA examiner failed to state whether this condition is the result of her time in active duty service, based upon the presumption set forth in 38 U.S.C.A. § 1154(b). As such, the appellant must be afforded a new VA gastrointestinal examination to determine the nature and etiology of her current GERD. Concerning the appellant's claims for increased disability ratings for her heels, hips, knees and chronic cystitis, the Board is aware that the last VA examinations for these conditions were conducted in 2004. The duty to assist includes conducting a thorough and contemporaneous examination of a veteran that takes into account the records of prior medical treatment. See Green v. Derwinski, 1 Vet. App. 121 (1991). Accordingly, the appellant must be scheduled for new VA examinations to determine the current severity of these conditions. Accordingly, the case is REMANDED for the following action: 1. The AMC is requested to obtain any outstanding VAMC treatment records for the appellant, dated January 2006 to the present. Any response to this request should be memorialized in the appellant's claims file. 2. After any outstanding VA treatment records have been associated with the appellant's claims file, she should be scheduled for a VA neurological examination to determine the nature and etiology of her claimed headaches. The VA examiner should thoroughly review the appellant's claims file as well as a complete copy of this REMAND and note this has been accomplished in the examination report. The VA examiner should address the appellant's service treatment records in March 2004 and April 2004 as well as the VAMC treatment notes dated in July 2004, August 2004, November 2004 and February 2005, which provide contradicting complaints. The VA examiner should state whether it is at least as likely as not that the appellant currently suffers from headaches that are the result of her time in active duty service. The examiner should provide a complete rationale for any opinion provided. It would be helpful if the examiner would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means 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 that conclusion as it is to find against it. 3. After any outstanding VA treatment records have been associated with the appellant's claims file, she should be scheduled for a VA audiological examination to determine the nature and etiology of her claimed bilateral tinnitus. The VA examiner should thoroughly review the appellant's claims file as well as a complete copy of this REMAND and note this has been accomplished in the examination report. The VA examiner is requested to address that acoustic trauma in service has been conceded. The VA examiner should also discuss the December 2004 VA audiological examination report and the VA treatment records dated in February 2005 and January 2006 pertaining to tinnitus. The VA examiner should state whether it is at least as likely as not that the appellant currently suffers from bilateral tinnitus that is the result of her time in active duty service. The examiner should provide a complete rationale for any opinion provided. It would be helpful if the examiner would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means 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 that conclusion as it is to find against it. 4. After any outstanding VA treatment records have been associated with the appellant's claims file, she should be scheduled for a VA orthopedic examination with an appropriate expert. The VA examiner should thoroughly review the appellant's claims file as well as a complete copy of this REMAND and note that this has been accomplished in the VA examination report. The VA examiner should explain in detail the current severity of the appellant's service-connected bilateral heel, bilateral hip and bilateral knee disabilities. 5. After any outstanding VA treatment records have been associated with the appellant's claims file, she should be scheduled for a VA digestive and esophageal examination with an appropriate expert. The VA examiner should thoroughly review the appellant's claims file as well as a complete copy of this REMAND and note that this has been accomplished in the VA examination report. The VA examiner is requested to address that the appellant suffered from GERD in service. The VA examiner should state whether it is at least as likely as not that the appellant currently suffers from GERD that is the result of her time in active duty service. The examiner should provide a complete rationale for any opinion provided. It would be helpful if the examiner would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means 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 that conclusion as it is to find against it. The VA examiner should also explain in detail the current severity of the appellant's service-connected chronic cystitis. 6. Thereafter, the AMC must review the claims file to ensure that the foregoing requested development has been completed. In particular, review the requested medical opinions to ensure that they are responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 7. After completing the above action and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims should be readjudicated. If the claims remain denied, a Supplemental Statement of the Case should be provided to the appellant and her representative. After they have had an adequate opportunity to respond, this issue should be returned to the Board for further appellate review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the appellant until further notice. However, the Board takes this opportunity to advise the appellant that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of her claims. Her cooperation in VA's efforts to develop her claims, including reporting for any scheduled VA examination, is both critical and appreciated. The appellant is also advised that failure to report for any scheduled examination may result in the denial of a claim. See 38 C.F.R. § 3.655 (2009). These claims 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 2002 & Supp. 2009). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs