Citation Nr: 1124845 Decision Date: 06/30/11 Archive Date: 07/06/11 DOCKET NO. 09-40 069 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for a skin condition. 2. Entitlement to service connection for a cervical spine disability. 3. Entitlement to service connection for alopecia. 4. Entitlement to service connection for a right knee disability. 5. Entitlement to service connection for an upper respiratory disorder, to include sinusitis and allergic rhinitis. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs ATTORNEY FOR THE BOARD L. J. Wells-Green, Counsel INTRODUCTION The Veteran served on active duty from June 2000 to August 2008. This matter comes to the Board of Veterans' Appeals (Board) on appeal from December 2008 and January 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. Although the Veteran's claim for service connection has previously been identified and developed as entitlement to service connection for a sinus condition, based on his description of his symptoms and the medical evidence of record, as will be discussed further, the Board finds that his claim also reasonably encompasses his diagnosed allergic rhinitis. See Clemons v. Shinseki, 23 Vet. App. 1 (2009)(United States Court of Appeals for Veterans Claims found that a claim for benefits for one psychiatric disability also encompassed benefits based on other psychiatric diagnoses and should be considered by the Board to be within the scope of the filed claim). Therefore, the issue on the title page has been modified to reflect the current disability. The issues of entitlement to service connection for a right knee disability and a respiratory disability, to include sinusitis and allergic rhinitis, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appellant's appeal has been obtained. 2. A current skin condition, to include pitted keratolysis of the feet with hyperhidrosis of the feet and axilla, did not have its onset in service and has not been etiologically linked to the Veteran's service or any other incident therein. 3. A cervical spine disability is not shown by the competent evidence of record. 4. The competent evidence does not show that the Veteran's congenital alopecia worsened in service beyond the natural progression or as a result of a superimposed disease or injury. CONCLUSIONS OF LAW 1. A skin condition, to include pitted keratolysis of the feet with hyperhidrosis of the feet and axilla, was not incurred in active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 2. A cervical spine disability was not incurred in active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 3. Alopecia was neither incurred in nor aggravated by active military service. 38 U.S.C.A. §§ 1110, 1111, 1131, 1153, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties To Notify And Assist When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Specifically, 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 that pertains to the claim. 38 C.F.R. § 3.159, as amended, 73 Fed. Reg. 23353-56 (Apr. 30, 2008); see Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). This notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini II, 18 Vet. App. at 119. Further, upon receipt of an application for a service-connection claim, VA is required to review the evidence presented with the claim and to provide the Veteran with notice of what evidence not previously provided will help substantiate his/her claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the Veteran of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the claim for service connection has been substantiated, and any defect in the notice regarding that claim was therefore not prejudicial to the claim. See Dingess, 19 Vet. App. at 491. In reviewing the Veteran's claims of entitlement to service connection for a skin condition, a cervical spine disability and alopecia, the Board observes that the RO issued VCAA notice to the Veteran in May 2008, June 2008 and April 2010 letters which informed him of the evidence generally needed to support claims of entitlement to service connection; what actions he needed to undertake; and how the VA would assist him in developing his claims. The letters also informed him of the evidence needed for the assignment of evaluations and effective dates for initial awards of service connection. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The May 2008 and June 2008 VCAA notices were issued prior to the December 2008 and January 2009 rating decisions from which the instant appeals arise. Thus, the Board concludes that the RO provided appropriate notice of the information or evidence needed in order to substantiate the claims prior to the initial decisions. In view of this, the Board finds that VA's duty to notify has been fully satisfied with respect to these claims. VA has secured or attempted to secure all relevant documentation to the extent possible. The Board notes that the Veteran's service treatment records, VA medical treatment records and evaluations are of record, as well as private treatment records and evaluations, and the Veteran's written contentions regarding the circumstances of his disabilities. These records were reviewed by both the RO and the Board in connection with the Veteran's claims. With respect to the VA compensation examinations and opinions provided the Veteran in June 2008, December 2008 and August 2010, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this case, the Board finds that the VA general medical examination reports are adequate, as they were predicated on a review of the claims files and all pertinent evidence of record as well as on physical examinations, and provided opinions regarding whether the Veteran's alleged disabilities were incurred in or caused by his service; the examiners supplied explanations for their conclusions. Therefore, the Board finds that these opinions provide adequate bases for deciding the claims. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). There remains no issue as to the substantial completeness of the Veteran's claims. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002); 38 C.F.R §§ 3.102, 3.159, 3.326(a) (2010). Any duty imposed on VA, including the duty to assist and to provide notification, has been met. Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Sanders v. Nicholson, 487 F. 3d (Fed. Cir. 2007). Analysis The Veteran and his representative contend that he currently has a skin condition and a cervical spine disability as a result of his service. The Veteran also contends that although he was diagnosed with alopecia prior to his military service, he did have hair at that time and that he subsequently lost all of his hair while in service. He believes that his service aggravated this condition. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish direct service connection for a disorder, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Skin Condition The Board acknowledges that the Veteran is competent to give evidence about what he has experienced, i.e., in this case, that he had skin rashes in service. Charles v. Principi, 16 Vet. App. 370 (2002) (finding the veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). However, as a layman without proper medical training and expertise, the Veteran is not competent to provide probative medical evidence on a matter such as the diagnosis or etiology of a specific skin disorder. Espiritu v. Derwinski, 2 Vet. App. 492, 494-495 (1992). For example, he is competent to say that he has a rash on his skin or has felt itching, but he is not competent to state that that rash or itching is eczema as opposed to some other specific diagnosis. Moreover, competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("Although interest may affect the credibility of testimony, it does not affect competency to testify."). After carefully considering all of the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a skin condition. The Veteran's service treatment records show that he was seen for complaints of chronic Athlete's foot of the right foot on one occasion in November 2004. The "problem" for the visit was noted as chronic Athlete dermatophylosis of foot. On examination, the examiner's objective finding was fungal appearing lesion on foot. The assessment was tinea pedis. In March 2005, while hospitalized for other complaints, the Veteran complained of a rash on his chest. He reported that the rash had begun approximately one year earlier upon his return from Iraq. Testing suggested the rash was of a fungal etiology and topical treatment was started. An April 2006 post-deployment health assessment shows the Veteran denied any skin diseases or rashes. However, in April 2008, the Veteran reported he got watery blisters on his feet. There was no accompanying examination or assessment. Service treatment records show no subsequent complaints, findings, treatment or diagnoses for a skin condition. Although medical evidence reveals that the Veteran currently suffers from pitted keratolysis of the feet with hyperhidrosis of feet and axilla, the Board finds that preponderance of the competent evidence of record does not etiologically link the Veteran's current skin disability to his service or any incident therein. In fact, the August 2010 VA examiner, in a later addendum, opined that it is less likely than not that the Veteran's pitted keratolysis is related to his military service, noting that it is unrelated to his in-service symptoms. The examiner further opined that the Veteran's congenital developmental hyperhidrosis is the cause of his pitted keratolysis. There is no medical opinion of record etiologically linking his current pitted keratolysis to his service. As noted above, the medical evidence of record indicates that the Veteran was not treated for any relevant complaints associated with pitted keratolysis in service, and medical evidence indicates that he was initially diagnosed with pitted keralolysis in April 2009. VA requested the Veteran submit evidence etiologically linking his current skin disability to his service or any incident therein. However, he has not submitted any medical evidence etiologically linking his current pitted keralolysis to service or any incident therein. Likewise, the preponderance of the competent evidence of record does not indicate that the Veteran has any other current diagnosis of a skin disability. Although VA treatment records, dated as early as September 2008, note the Veteran's complaints of intermittent rashes since his return from Iraq, most show no objective evidence of a skin condition other than his diagnosed pitted keralolysis. However, a February 2009 treatment record indicates that dryness and scales were noted on both the Veteran's hands and nails and an April 2009 treatment record shows he had pruritic lesions on his legs. Neither record shows a diagnosis and the February 2009 treatment record appears to associate his symptoms with his diagnosed alopecia. These are the only treatment records showing any skin symptoms other than his pitting keralolysis and alopecia after the Veteran's discharge from service. In contrast, the vast majority of the objective treatment records merely show the Veteran's complaints, but note that examination of the skin repeatedly revealed no evidence of rashes or reported that examination of the skin was normal. In this respect, despite the Veteran's report of having recurrent warts intermittently since 2002, as well as recurrent truncal rashes and fungal foot conditions, the June 2008 VA examiner found no evidence of a skin condition. Likewise, a December 2008 VA examiner found an examination of the Veteran's skin to be normal, with no evidence of lesions or blisters. During the August 2010 VA examination, the examiner notes that the Veteran's claim was for dry intermittent patches of itchy skin that was prevalent in winter and was unrelated to his feet or alopecia. However, no lesions were found during physical examination and the diagnosis was acute eczema. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110, 1131; see Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disabilities for which benefits are being claimed. Thus, the medical evidence does not establish that the Veteran currently has any chronic skin condition other than his diagnosed pitting keralolysis and his alopecia which will be subsequently addressed. Although the Veteran believes he currently has a skin condition, which he describes as a recurrent rash, since service, and he is competent to provide evidence of his in-service experiences, the Board finds that this issue does not involve a simple diagnosis. See Jandreau; see also Woehlaert, supra. In this respect, while the Veteran believes he has a distinct skin condition which had its onset during service, he is not competent to provide evidence that requires medical knowledge. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). There is no indication in the record that the Veteran is a physician or other health care professional. Therefore, as a layperson, he is not competent to provide evidence that requires medical knowledge because he lacks the requisite professional medical training, certification and expertise to present opinions regarding diagnosis and etiology. Thus, his lay assertions with regard to whether his currently diagnosed pitting keralolysis is etiologically related to the skin symptoms he had in service service or any incident therein or that he has any other diagnosed skin condition are not competent or sufficient. To the extent that the Veteran asserts continuity of the symptoms associated with a recurrent skin condition since service, available private and VA treatment records, as well as VA compensation examinations, dating from June 2008, while noting his complaints, show no relevant findings, treatment or diagnoses. The Board finds the August 2010 VA examiner's opinion more probative than the Veteran's assertions, as the examiner's opinion was based on a review of the Veteran's claims file and the examiner provided thorough rationale for his opinion that incorporated the Veteran's post-service treatment records as well as his service treatment records and reported history. While the Board finds the Veteran is competent to say that he has experienced recurrent and intermittent skin rashes and lesions on his chest and upper legs since service, his statements are directly contradicted by the contemporaneous treatment records. In this regard, this is not a case where there is an absence of post-service medical evidence, but rather the treatment records show the Veteran's complaints but not a diagnosed skin disorder on examination. Cf. Kahana v. Shinseki, No. 09-3525, slip op. at 14-15 (U.S. Vet. App. June 15, 2011) (Lance, J., concurring) (noting that, in cases involving combat, VA is prohibited from drawing an inference from silence in service medical records (SMRs), but explaining that in cases where such an inference is not prohibited, VA may use silence in the SMRs as contradictory evidence if the SMRs appear to be complete and the injury, disease, or symptoms involved would ordinarily have been recorded had they occurred). The Board finds this contemporaneous evidence to be more probative and credible than the Veteran's current assertions. See Curry v. Brown, 7 Vet. App. 59, 68 (1994). Accordingly, for the reasons noted above, the Board concludes that the preponderance of the evidence is against the claim in this case, and service connection for headaches must be denied. 38 U.S.C.A. § 5107(b). In reaching this determination, the Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Cervical Spine Disability After carefully considering all of the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a cervical spine disability. Initially, the Veteran's service treatment records show he complained of neck and thoracic pain after running and doing a ruck march in May 2006. The assessment was cervical and thoracic strain. There are no further complaints, findings, treatment or diagnosis of a cervical spine disability during service. Likewise, the preponderance of the competent evidence of record does not indicate that the Veteran has a current diagnosis of a cervical spine disability. Although private treatment records, dating from September 2008 to December 2008, show treatment for thoracic and lumbar spine complaints, there are no relevant complaints or treatment for a neck or cervical spine disability. VA treatment records, dated as early as September 2008 show no relevant complaints, findings, treatment or diagnoses. Moreover, the June 2008 VA examination report shows that the Veteran reported his cervical spine complaints had resolved and he had no symptoms in the cervical region. The examiner noted that examination of the cervical spine was normal with full cervical spine range of motion. There was no associated diagnosis. The Board finds the June 2008 VA examination report showing no current symptoms in the cervical region and a normal examination to be more probative than the Veteran's belief that he has a current cervical spine disability, as the VA examiner relied on a review of the Veteran's treatment records and an examination. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110, 1131; see Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disabilities for which benefits are being claimed. Thus, the medical evidence does not establish that the Veteran currently has a cervical spine disability. Although the Veteran believes he currently has a cervical spine disability and he is competent to provide evidence of his in-service experiences, the Board notes that he has provided no contentions regarding an alleged neck or cervical spine disability. In this respect, the Veteran appears to rely on treatment records addressing thoracic spine complaints as evidence of a cervical spine disability. The Board further notes that the Veteran has not appealed an earlier denial of his claim for service connection for a lumbar/thoracic spine disability. In any event, the Board finds his contentions to be less credible that the contemporary service treatment records which show he treated on only one occasion for an assessed cervical strain, with no subsequent complaints, findings, treatment or diagnoses. Accordingly, the claim for service connection for a cervical spine disability must be denied. Alopecia Congenital or developmental defects are not "diseases or injuries" within the meaning of applicable statutes and regulations. 38 C.F.R. § 3.303(c). However, where during service a congenital or developmental defect is subject to a superimposed injury or disease, service connection may be warranted. VAOPGCPREC 82-90 (July 18, 1990), published at 56 Fed. Reg. 45,711 (1990) (a reissue of General Counsel opinion 01- 85 (March 5, 1985). The VA General Counsel's opinion indicated that there is a distinction under the law between a congenital or developmental "disease" and a congenital "defect" for service connection purposes in that congenital diseases may be recognized as service connected if the evidence as a whole shows aggravation in service within the meaning of VA regulations. A congenital or developmental "defect," on the other hand, because of 38 C.F.R. § 3.303(c), may not be service-connected although service connection may be granted for additional disability due to disease or injury superimposed upon such defect during service. VAOPGCPREC 82-90. Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. History provided by the veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). To rebut the presumption of sound condition under section 1111 of the statute for disorders not noted on the entrance or enlistment examination, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). Clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). It is an "onerous" evidentiary standard, requiring that the no-aggravation result be "undebatable". Cotant v. West, 17 Vet. App. 116, 131 (2003) (citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993) (citing Akins v. Derwinski, 1 Vet. App. 228, 232 (1991). Concerning clear and unmistakable evidence that the disease or injury was not aggravated by service, the second step necessary to rebut the presumption of soundness, a lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 U.S.C.A. § 1153. In this regard, temporary or intermittent flare-ups of symptoms of a preexisting condition, alone, do not constitute sufficient evidence to show increased disability for the purposes of determinations of service connection based on aggravation unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). A presumption is an assumption of fact resulting from a rule of law which requires such fact to be assumed from another fact or group of facts found or otherwise established in the action. Black's Law Dictionary 1067 (5th ed. 1979). Therefore, where the presumption of sound condition at entrance to service cannot be rebutted, the fact for which the presumption stands--that is, that the veteran was in sound condition at entry to service as to the disability for which he seeks service connection--must be assumed as a matter of law. Accordingly, service connection may not be granted on the basis of aggravation of a preexisting disease or injury in such a case. Rather, where the government fails to rebut the presumption of soundness under section 1111, the veteran's claim must be considered one for service incurrence or direct service connection. See Wagner, 370 F.3d at 1094, 1096 (indicating that, in cases where the presumption of soundness cannot be rebutted, the effect is that claims for service connection based on aggravation are converted into claims for service connection based on service incurrence). In considering all of the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for alopecia. The Veteran contends that his pre-existing alopecia was aggravated by his service. In particular, the Veteran contends that while he had been diagnosed with alopecia in high school, he still had hair when he entered service. He asserts that he lost all of his hair during service, despite steroidal treatment, and that his condition therefore worsened. The Veteran is contending that he is entitled to service connection for alopecia on an aggravation basis. The Veteran's August 1999 enlistment medical examination report shows he had alopecia areata. October 2002 service treatment records note that he had had alopecia areata since childhood and had been without hair for 3 years. The assessment was alopecia universalis. Subsequent treatment show steroidal treatment for alopecia universalis was unsuccessful. During the June 2008 VA examination, the examiner diagnosed alopecia universalis. The examiner noted that alopecia universalis is a congenital/developmental condition. The examiner opined that it was not plausible that service aggravated this condition. The December 2008 VA examiner, diagnosing the condition as vitiligo, also stated that there was no plausible cause or permanent aggravation present, that it is the result of a natural pre-service condition. The Board notes that congenital or developmental defects are not "diseases or injuries" within the meaning of applicable statutes and regulations. 38 C.F.R. § 3.303(c). However, if during service a congenital or developmental defect is subject to a superimposed injury or disease, service connection may be warranted. VAOPGCPREC 82-90 (July 18, 1990), published at 56 Fed. Reg. 45,711 (1990) (a reissue of General Counsel opinion 01- 85 (March 5, 1985). Whether or not the Veteran's alopecia is a congenital defect or disease, it clearly pre-existed service. The June 2008 and December 2008 examiners, while not clarifying defect or disease, opined that it was not plausible that the condition had been aggravated by the Veteran's service. The examiners noted that the Veteran's total loss of his hair in service was the natural progression of the condition and was not aggravated. Nor is there any indication of a superimposed disease or injury in the service treatment records. Accordingly, as there is no evidence of a superimposed disease or injury on the alopecia, or of aggravation of this pre-existing condition, service connection cannot be granted. The Board affords the opinions of the VA examiners greater probative value as they were based on a review of the claims file and were supported by an adequate rationale. In contrast, although the Veteran might sincerely believe that his alopecia was aggravated by his service, he, as a layperson, is not qualified to render a medical opinion as to etiology or diagnosis. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). As such, service connection must be denied. 38 C.F.R. § 3.303. ORDER Service connection for a skin condition is denied. Service connection for a cervical spine disability is denied. Service connection for alopecia is denied. REMAND VA is required to provide a medical examination when the record of the claim does not contain sufficient medical evidence for VA to adjudicate the claim. See 38 U.S.C.A. § 5103A (d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2010). With respect to the Veteran's claim of entitlement to service connection for a respiratory disorder, the Board finds that a new examination is warranted. As noted previously, the Veteran specifically claimed service connection for shortness of breath and sinusitis. Service treatment records do show that the Veteran had a history of exercise induced asthma and was treated intermittently for respiratory complaints diagnosed as upper respiratory infections, allergic rhinitis and, on one occasion, sinusitis. The post-service treatment records reveal diagnoses of allergic rhinitis. As noted above, in Clemons v. Shinseki, the Court held that VA should consider all possible diagnoses arising from similar symptoms. Therefore, the Veteran's claim is more appropriately characterized as entitlement to service connection for a respiratory disorder, to include sinusitis and allergic rhinitis. Although the Veteran was afforded VA examinations in June 2008 and August 2010, and the examiner, in August 2010 offered an opinion regarding the Veteran's upper respiratory infections in service, he did not provide an opinion regarding the Veteran's diagnosed rhinitis. The current medical evidence shows several diagnoses of rhinitis. As the examination does not address the etiology of this condition, a new VA examination is required. 38 C.F.R. § 3.159(d) (2010). Likewise, although the Veteran has been provided examinations in June 2008, December 2008, and August 2010, in which the Veteran found no current right knee pathology, both service treatment records and post-service treatment records repeatedly note the Veteran's complaints and show diagnoses that include patella femoral syndrome. Moreover, the VA examiner, who conducted all 3 of the compensation examinations, did not adequately address VA treatment records dated in March 2010 and April 2010 and showing right knee instability, in his opinion that the Veteran does not have a current right knee disability. The Board therefore finds that the Veteran should again be afforded VA respiratory and orthopedic examinations to determine the current nature, extent and etiology of any respiratory and/or right knee disabilities found to be present. See 38 U.S.C.A § 5103A (West 2002); 38 C.F.R. § 3.159(c)(4), 3.310 (2009); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Finally, the Board notes that the Veteran's most recent VA treatment records are dated in June 2010. Copies of any available VA records subsequent to June 2010 need to be obtained and incorporated in the claims files. It is important to note that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of that claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). These treatment records should be associated with the claims files. 38 U.S.C. § 5103A (West 2002). Accordingly, the case is REMANDED for the following action: 1. VA should obtain any VA treatment records, dating from June 2010 to the present, and associate the records with the Veteran's claims files. 2. After the above development has been completed to the extent possible, the Veteran should be afforded a VA examination, with a physician specializing in respiratory disabilities to assess the nature and etiology of any currently diagnosed respiratory disability, to include rhinitis and sinusitis, if found to be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is also requested to review all pertinent records associated with the claims files and acknowledge such review in the examination report. Based on the medical findings and a review of the claims files, the examiner should specifically opine as to whether it is at least as likely as not that the Veteran's respiratory disability is causally related to his service. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the 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. The examiner should set forth the complete rationale for all opinions expressed and conclusions reached, in a legible report. 3. The Veteran should also be afforded another VA orthopedic examination to determine the current nature and etiology of any current right knee disability found to be present. All necessary studies or tests should be accomplished and the examiner must review the evidence in the claims folders, including a complete copy of this REMAND, and acknowledge such review in the examination report. If the examiner diagnoses a right knee disability, the examiner should offer an opinion as to whether it is at least as likely as not that the Veteran's right knee disability is etiologically related to his service or any incident therein. If the examiner finds there is no current right knee disability, he/she should address recent treatment records noting right knee instability in providing an opinion. If the examiner is unable to provide the requested information with any degree of medical certainty, the examiner should clearly indicate that. The examiner should set forth the complete rationale for all opinions expressed and conclusions reached. 4. Thereafter, VA should readjudicate the issues on appeal. If the issues on appeal remain denied, a supplemental statement of the case should be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal should be returned to the Board for appellate review. 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. 2010). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs