Citation Nr: 1300519 Decision Date: 01/07/13 Archive Date: 01/11/13 DOCKET NO. 07-03 632 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to service connection for a right ear disability, to include otitis media and chronic Eustachian tube blockage. 3. Entitlement to service connection for a right knee disability. 4. Entitlement to service connection for a left knee disability. 5. Entitlement to a compensable rating residuals of a perforated right tympanic membrane. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD B. Diliberto, Counsel INTRODUCTION The Veteran had active service from June 1982 to November 1983. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from May 2005 and December 2005 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, that denied the benefits sought on appeal. During the pendency of the appeal the Veteran was afforded a hearing before a Decision Review Officers at the RO. In a February 2006 statement the Veteran requested a hearing before the Board. However, in his December 2006 Substantive Appeal (VA Form 9), the Veteran indicated that he no longer wanted to appear at a hearing before a Veterans Law Judge. Accordingly, the Board considers the Veteran's hearing request to have been withdrawn. 38 C.F.R. § 20.704(d) (2012). The Veteran's claim first came before the Board in May 2011, at which time it was remanded for further development. The requested development has now been completed, and no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). The Board has reviewed the Veteran's physical claims file and the Veteran's Virtual VA electronic file to ensure a total review of the evidence. FINDINGS OF FACT 1. The Veteran's does not have right ear hearing loss disability which began in service or has been shown to be causally or etiologically related to service. 2. The Veteran's does not have a non-hearing loss right ear disability, to include otitis media and chronic Eustachian tube blockage, which began in service or has been shown to be causally or etiologically related to service. 3. The Veteran's does not have a right knee disability which began in service or has been shown to be causally or etiologically related to service. 4. The Veteran's does not have a left knee disability which began in service or has been shown to be causally or etiologically related to service. 5. The Veteran's service-connected residuals of a perforated right tympanic membrane are assigned a 0 percent disability rating, the maximum rating authorized under Diagnostic Code 6211. CONCLUSIONS OF LAW 1. The criteria for service connection for right ear hearing loss have not been met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for a right ear disability, to include otitis media and chronic Eustachian tube blockage, have not been met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 3. The criteria for service connection for a right knee disability have not been met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 4. The criteria for service connection for a left knee disability have not been met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 5. The criteria for a compensable rating for a history of a perforated right tympanic membrane have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.21, 4.87, Diagnostic Code 6211 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has claimed entitlement to service connection for right ear hearing loss, a non-hearing loss right ear disability, a right knee disability, and a left knee disability. He has also claimed entitlement to a compensable rating for his service-connected residuals of a perforated right tympanic membrane. In general, service connection will be granted for disability resulting from injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). If there is no showing of a resulting chronic disability 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) (2012). Service connection may also be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Certain chronic disabilities, such as organic diseases of the nervous system like sensorineural hearing loss, are presumed to have been incurred in service if manifested to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1133 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). To prove service connection, the record must contain: (1) evidence of a current disability, (2) evidence, or in certain circumstances, lay testimony, of an in-service incurrence or aggravation of injury or disease, and (3) evidence of a nexus or relationship between the current disability and the in-service disease or injury. Coburn v. Nicholson, 10 Vet. App. 427 (2006); Disabled American Veterans v. Secretary of Veterans Affairs, 419 F. 3d 1317 (Fed. Cir. 2005). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In addition, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992). 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. Once service connection has been granted disability evaluations are determined by evaluating the extent to which a veteran's service-connected condition adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set in the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify various disabilities and the criteria for specific ranges. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinksi, 1 Vet. App. 589 (1991). If two disability ratings are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). While the veteran's entire history is reviewed when assigning a disability rating, where service connection has already been established, and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Moreover, separate ratings can be assigned for separate periods of time based on the facts found. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. Ap. 119 (1999). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2012). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all findings specified. 38 C.F.R. § 4.21 (2012). The Board will consider the potential application of the various other provisions of 38 C.F.R., Parts 3 and 4, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The assignment of a particular diagnostic code is completely dependent on the facts of a particular case. Butts v. Brown, 5 Vet. App. 532 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). A claim for a total disability rating by reason of individual unemployability due to service-connected disability (TDIU) is considered part and parcel of an increased-rating claim when the issue of unemployability is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran has not asserted that his service-connected disability has resulted in unemployability. Therefore, consideration of a TDIU is not warranted. The Veteran first filed a claim asserting entitlement to service connection for certain disabilities in August 1988. In a May 1990 rating decision, the RO denied service connection for hearing loss and serous otitis media. The Veteran did not appeal those decision. Accordingly, they are final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2012). The RO also granted service connection for a scar on the posterior right tympanic membrane, and assigned a 0 percent rating, effective January 5, 1990. In July 1993 the Veteran claimed entitlement to an increased rating for his service-connected posterior right tympanic membrane scar. The RO denied an increased rating in a December 1993 rating decision. In January 2005 the Veteran filed a claim attempting to reopen his previous denied claim of entitlement to service connection for hearing loss. A May 2005 rating decision found that new and material evidence had not been submitted and declined to reopen the previous decision. In August 2005, the Veteran filed a claim attempting to reopen his claims for hearing loss and serous otitis media. The Veteran also claimed entitlement to service connection for right and left knee disabilities and entitlement to an increased rating for his service-connected posterior right tympanic membrane scar. In December 2005 the RO reopened the claim of entitlement to service connection for hearing loss, but did not reopen the claim for serous otitis media, finding that new and material evidence had not been submitted. The RO denied entitlement to service connection for hearing loss after a de novo review and also denied entitlement to service connection for right and left knee disabilities. Moreover, the RO denied entitlement to a compensable rating for the Veteran's service-connected posterior right tympanic membrane scar. The Veteran's claim first came before the Board in May 2011. At that time the Board reopened the Veteran's claims of entitlement to service connection for right ear hearing loss and right serous otitis media. The Board then remanded those claims, and also remanded the claims of entitlement to service connection for right and left knee disability and the claim of entitlement to a compensable rating for the Veteran's service-connected residuals of a perforated right tympanic membrane. The development requested in that remand has now been completed, and no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the claim is again before the Board. Right Ear Hearing Loss & Disabilities The Veteran has claimed entitlement to service connection for right ear hearing loss and non-hearing loss disabilities of the right ear, including otitis media and chronic Eustachian tube blockage. Prior to the Board's May 2011 remand, those claims were characterized as entitlement to service connection for bilateral hearing loss and entitlement to service connection for serous otitis media. However, based on an August 2006 statements from the Veteran wherein the Veteran indicated that he was only seeking service connection for right ear problems, the Board recharacterized those issues. The relevant evidence of record on those issues includes service medical records, VA treatment records, VA examination reports, and written and oral statements from the Veteran. The Veteran's service medical records from July 1982 indicate that the Veteran was treated for bleeding from his right ear. The Veteran reported that an ear swab was pushed into his ear by accident approximately a day earlier. Physical examination revealed that the ear canal was blocked by dried blood. Soft tissue trauma was assessed, but the tympanic membrane appeared clear and mobile. Records from December 1982 indicate that the Veteran was diagnosed with strep and that his tympanic membranes were cloudy. The Veteran's discharge examination from October 1983 indicates that his hearing was normal for VA evaluation purposes as no threshold higher than 20 decibels was noted at any relevant frequency. 38 C.F.R. § 3.385 (2012). Private treatment records from April 1985 indicate that the Veteran reported right ear pain with a two month history. The Veteran's tympanic membranes were clear, but tenderness was noted just inferior to the ear. Right serous otitis media was diagnosed. Records from later that month indicate that that Veteran again reported having a right ear ache. He also reported an inability to chew on his right side. Temporomandibular joint dysfunction was diagnosed. In March 1990, the Veteran was scheduled for a VA examination in support of his claim. During that examination the Veteran reported that he ruptured his right tympanic membrane in service and that he underwent surgical repair. He stated that he had subsequently been aware of a throbbing right ear ache at times of excitement or when exposed to loud sounds. He denied any tinnitus or hearing loss. Physical evaluation revealed that the auditory canals and tympanic membranes were clear, except for a posterior scar on the right tympanic membrane. Tuning fork testing, Weber testing, and Rinne testing revealed normal hearing. In September 1993, the Veteran was afforded an additional VA examination. Physical examination revealed that the right ear canal was clear and that the tympanic membrane was normal. A healed traumatic perforation of the tympanic membrane was diagnosed. An audiogram revealed normal hearing in the left ear. The right ear audiogram revealed thresholds of 25 decibels at 1000 hertz, 5 decibels at 2000 hertz, 15 decibels at 3000 hertz and 15 decibels at 4000 hertz. The speech recognition score for that ear was 94 percent. Normal hearing was noted bilaterally. Subsequent VA treatment records indicate that the Veteran's tympanic membranes were intact. No masses or legions were noted. Records from August 2005 indicate that the Veteran reported having had constant right ear pain since his ear injury in service. An assessment of inactive infection of the otitis externa was provided. Records from September 2005 indicate that the Veteran was assessed with Eustachian tube blockage. Records from October 2005 indicate that the external auditory canals were clear with intact tympanic membranes bilaterally. Mild hearing loss at 0.25kHz was noted, with normal hearing from 0.5kHz through 2kHz, mild sensorineural hearing loss at 3 kHz, normal hearing at 4 kHz and mild loss at 6 kHz and 8 kHz. Speech reception thresholds and work recognition score were within normal limits. Tympanogram was also within normal limits, though Eustachian function testing indicated poor function. The Veteran was afforded another VA examination in November 2005. During that examination the Veteran stated that for the previous ten years he experienced pain in his right ear when on a plane or while swimming. He also reported transient vertigo. Physical examination revealed that the auricle and external auditory canals were clear bilaterally. There was no evidence of lesions, inflammation, effusion, cholesteatoma, or retraction pockets. The middle ear showed mobile bilateral tympanic membranes. There was no evidence of mastoiditis or any other middle ear disease. Palpation of the face showed evidence of crepitans and wide excursion of the temporomandibular joint bilaterally, which the examiner stated was consistent with temporomandibular joint disease. Audiometric testing revealed right ear hearing thresholds of 30 decibels at 500 Hertz, 15 decibels at 1000 Hertz, 15 decibels at 2000 Hertz, 35 decibels at 3000 Hertz, and 25 decibels at 4000 Hertz. The average threshold was 17 decibels and the word recognition score for that ear was 92 percent. The examiner noted that these results showed flat/rising sensorineural hearing loss in the mild range on the right side. There was some mild asymmetry and there appeared to be a very subtle conductive component. Discrimination was 96 percent bilaterally. The examiner's assessment was a history of right tympanic membrane perforation. The examiner stated that the tympanic membrane was perfectly healed, without any evidence of trauma or scar. The examiner noted the Veteran's slightly asymmetric sensorineural hearing loss, stating that it was not consistent with a loud noise-related loss, as it arose from low frequencies. The examiner stated that there was no worsening of the Veteran's middle ear disease as the right tympanic membrane appeared normal and that any relation to hearing loss in the right ear could not be resolved without resorting to mere speculation. In his February 2006 notice of disagreement, the Veteran stated that his right ear had become very painful over the years. In May 2007 the Veteran testified at a hearing before a Decision Review Officer. During that hearing the Veteran reported that he served as a radio operator during his period of active service. He stated that he injured his ear when a fellow soldier bumped his arm while he was using an ear swab. He reported that the ear swab was surgically removed and that three sutures were put in his eardrum. He stated his belief that caused his hearing loss and his ear pain. An additional VA examination was performed in July 2011. During that examination the Veteran reported hearing loss and pain. In-service noise exposure was noted and the Veteran related having sustained a traumatic tympanic membrane perforation in 1982. In conducting a review of the claims file, the examiner noted that the Veteran's induction physical revealed normal hearing through 4000 Hertz and severe loss at 6000 Hertz in both ears. The examiner stated that finding may have been invalid as it appeared that the stimulus tone may have been turned off or another type of problem may have existed, noting that it was very unusual to see that type of loss. The examiner also noted that treatment records from October 1983 revealed normal hearing, that records from July 1982 showed evaluation for a right tympanic membrane perforation, and that records from August 1982 indicated slight scarring of the right tympanic membrane. The examiner noted that the Veteran sought treatment for serous otitis media in 1985 and that the Veteran was evaluated at the VA in September 1993, at which time normal hearing was shown. Audiometric testing revealed right ear hearing thresholds of 25 decibels at 500 Hertz, 20 decibels at 1000 Hertz, 30 decibels at 2000 Hertz, 35 decibels at 3000 Hertz and 30 decibels at 4000 Hertz. The average threshold was 28.75 decibels and the speech recognition score for that ear was 94 percent. The examiner noted that imittance revealed slightly reduced tympanic membrane mobility in the right ear and normal mobility in the left ear. All acoustic reflexes were present in both ears. The examiner stated that the results did not support an active middle ear pathology. The examiner diagnosed the Veteran with mild hearing loss, primarily in the right ear at 500 Hertz. The examiner could not opine if the change was related to the tympanic membrane perforation, noting that the Veteran would need to be examined by an otologist for all opinions related to the effects of the tympanic membrane perforation on the Veteran's daily living and occupation, whether the Veteran's ear disorder caused or aggravated his present hearing loss, and whether or not the Veteran still has recurrent ear pathology. However, the examiner stated that as the Veteran was discharged with normal hearing, it was less likely as not that his present hearing loss was the result of military noise exposure. An otological VA examination was performed in September 2011. The examiner conducted a thorough physical examination, noting that the Veteran's tympanic membranes were normal and that his external ear canals were unremarkable. The Veteran's turbinates were normal, without polypoid mucosa or edema and his Eustachian tube orifices had clear/yellow mucus without blockage. There was no evidence of otitis media or Eustachian tube dysfunction. The examiner stated that, with the normal audiogram on discharge, he would not relate the Veteran's hearing loss to activity in service. An October 2011 addendum to the examination report stated that the scarring of the right tympanic membrane may be secondary to the perforation, but that the perforation did not cause hearing loss based on the normal audiogram at discharge. The examiner stated that the injury in service did not cause any residuals and did not impact the Veteran's activities of daily living, including his ability to obtain and maintain employment. In October 2012, an independent medical opinion was obtained by the RO. The reviewer indicated having reviewed the claims file and relevant medical records. The examiner stated that the Veteran's slight right ear hearing loss was less likely than not caused or aggravated by his time in service. In so finding, the examiner noted that it was less likely than not that the tympanic membrane was perforated at the time of the in-service injury because the evaluating provider stated that the membrane was clear and mobile. The examiner noted that in cases where the tympanic membrane was perforated, the membrane was cut, foggy in appearance, immobile, and that middle ear structures are observed. Since those findings were not noted in the medical record, the examiner stated that it is probable that the Veteran damaged the external ear canal, causing the blood clot. The post-hearing observation of tympanic scarring was a normal finding, as pressure against the membrane ensued from the clot formation. In the rationale, the examiner also noted the normal hearing test score on discharge and the June 2011 VA examination report findings. The examiner concluded by reiterating that it was less likely than not that the Veteran's right ear condition was caused or aggravated by his time in service or a residuals of his in-service ear injury. The examiner stated that, in this case, it was at least as likely as not that the Veteran's slight loss of right ear hearing (perpcysis) was a normal condition of aging. In an October 2012 statement the Veteran reiterated his assertion that his right ear drum was punctured while on active service. He stated that the pressure in his right ear is very painful. After a thorough review of the entirety of the evidence of record, the Board finds that there is a preponderance of evidence against the Veteran's claims and that entitlement to service connection for right ear hearing loss and a non-hearing loss disability of the right ear, to include otitis media and chronic Eustachian tube blockage, is not warranted. To establish service connection for the claimed disability on a direct basis, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the two. With respect to the claimed non-hearing loss right ear disability, including otitis media and chronic Eustachian tube blockage, the Board notes that the Veteran's claim fails with because of the lack of evidence demonstrating that there is a current disability. There is no evidence that the Veteran currently has a non-hearing loss right ear disability other than his own lay statements, which are outweighed by the post-service medical records, including the afforded VA examination. Those reports consistently show that the Veteran does not have any non-hearing loss right ear disability. Those reports are persuasive because they were prepared by trained medical professionals. With respect to hearing loss, VA has specifically defined what is meant by a hearing loss disability for the purposes of service connection. 38 C.F.R. § 3.385 (2012). Impaired 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. The normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993). Although the evidence of record reveals that the Veteran does have a right ear hearing loss disability, that claim fails because of the lack of evidence of a nexus between a current disability and an in-service incurrence or injury. While the record shows that the Veteran injured his right ear in service, post-service medical records, including the VA examination reports and the October 2012 independent medical opinion, indicate that the Veteran's current right ear hearing loss is unrelated to his period of service and is more likely age-related. Those reports include thorough reviews of the evidence and well-reasoned medical opinions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The Board has considered the Veteran's assertions and acknowledges that he is competent to testify as to symptoms which are non-medical in nature or which come to him through his senses, such as the occurrence of an event or injury in service. However, individuals without training are not competent to provide evidence as to more complex medical questions. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran is not shown to have medical training and expertise, and so cannot provide a competent opinion on a matter as complex as the existence of a specific disability affecting his ear or the etiology of any hearing loss. Even according the Veteran's assertions some probative value, they are outweighed by the objective medical evidence provided by trained medical professionals indicating that he does not have a non-hearing loss right ear disability and that his right ear hearing loss is not related to his period of service or any injury therein. Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). A claimant has the responsibility to present and support a claim for benefits under laws administered by the VA. 38 U.S.C.A. § 5107(a) (West 2002). The Veteran was clearly advised of the need to submit medical evidence of the existence of the disabilities claimed and a relationship between those disabilities and the Veteran's period of service. The most persuasive and probative evidence of record fails to demonstrate that the Veteran actually has any non-hearing loss right ear disability or that his right ear hearing loss is related to his period of service or any injury therein. In sum, the Board finds that there is a preponderance of evidence against a grant of service connection for right ear hearing loss or a right ear non-hearing loss disability. As there is a preponderance of evidence against the claim, the claims must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Bilateral Knee Disabilities The Veteran has also claimed entitlement to service connection for right and left knee disabilities. The relevant evidence of record on those issues includes service medical records, VA treatment records, VA examination reports, and written and oral statements from the Veteran. The Veteran's service medical records indicate that he reported having pain in his right knee in December 1982. Radiographic imagery was normal and a mild sprain was diagnosed. In May 1983 the Veteran reported left leg pain and shin splints were diagnosed. The Veteran complained of injuring his left knee in August 1983. At that time the Veteran hit the inside of his knee. He reported pain while walking. Physical examination revealed a small amount of swelling over the medial aspect of the left knee. There was no heat or discoloration. The evaluating provider assessed the Veteran with a contusion. Post-service records are entirely negative for any treatment for diagnoses related to any type of knee disability until August 2005, at which time the Veteran filed his claim, stating that he had a knee disability that began in August 1983 and that he sometimes had to call out of work because of his knee. VA treatment records show that the Veteran first reported knee joint pains and unstable knees in August 2005, stating that had been occurring for the last ten years. The Veteran stated that his knee occasionally gave way while walking. Physical examination revealed normal gait and coordination. There were no deformities at the knee joints and no restriction of movement or muscle atrophy. Radiographic imagery was performed in September 2005. The evaluating provider's impression was early osteoarthritis bilaterally. The Veteran was afforded a VA examination in support of his claim in November 2005. During that examination the Veteran reported having significant pain and discomfort in the anterior aspect of both knees when climbing steps or walking on uneven terrain. He reported that he sustained a twisting injury to his right knee in service. He also reported a twisting injury to his left knee when he slipped and fell on some rocks. He stated that since those events he had been complaining of pain in both knees, with the right worse than the left. He also reported a giving way sensation that apparently was associated with a subluxation of the patella. The Veteran stated that he was able to walk about one mile on flat terrain, but could not walk more than five flights of stairs because of his knee pain. Physical examination revealed a symmetrical appearance to the knees. There was no muscle weakness or atrophy. Compression of the patellofemoral joint was negative for any pain or discomfort that could be associated with chondromalacia of the patella. Lachman's test was negative, as was McMurray's test. The medial and lateral collateral ligaments were intact. The patella was tracking in the midline and there was a rubbery-like structure perceived bilaterally on both knees in the medial compartment that was extremely painful to palpation. A mild synovitis was noted with crepitation. Full range of motion was obtained bilaterally. On repetitive action there was increased fatigue, lack of endurance and pain, but no decrease in the range of motion. The examiner diagnosed the Veteran with bilateral synovitis associated with painful medial plica synovialis, but stated that it was not at least as likely as not that the Veteran's knee disabilities were the result of active duty. In his February 2006 notice of disagreement, the Veteran reported that he injured his knee during basic training and then reinjured them on several other occasions. He stated that roughly 16 years ago his knees "just quit" on him and he sought treatment from the VA. He stated that for the last two years his knees had been substantially worse. In May 2007, the Veteran testified at a hearing before a Decision Review Officer. During that hearing, the Veteran stated that he had no problems with his knees prior to service, but that he injured his both knees when he tripped down some stairs in Korea in December 1982. He reported being put on profile for seven days until the swelling went down and that he was placed on profile again later for three days. He reported that from that time he had always had problems with his knees. He stated that he now had fairly constant pain in his knees and had difficulty squatting and walking up stairs. VA treatment records from November 2007 show continued treatment for knee pain, with physical therapy beginning in December 2007. The evaluating provider noted that the Veteran reported longstanding complaints of knee pain and instability. Records from April 2008 and June 2008 indicate that the Veteran was seen for orthopedic surgery consultations. The evaluating provider noted that an MRI revealed degenerative changes in the post-horn medial meniscus, and a small lateral tear. Conservative treatment was planned. Records from October 2008 show that the Veteran reported falling three weeks earlier and injuring his left knee. Records from November 2008 reference assessment of bilateral knee pain and a partial medial meniscus tear in the right knee. A joint injection was performed. In May 2011, the Veteran was afforded an additional VA examination in support of his claim. During the examination the Veteran reported that his knees hurt when he went up and down stairs or when he had to climb a slope. The Veteran stated that his knee pain was present in front of the knees and slightly to the inside and was localized. There was no evidence of radiation up or down the leg. Aggravated factors noted were overuse, and especially using stairs. There was no history of locking, but the Veteran reported that he had a feeling that his knee was about to give way. As part of the examination, the examiner conducted a thorough review of the entirety of the claims file, noting that the service treatment records indicated treatment for a right knee injury in December 1982, complaints of shin splints in May 1983, and complaints of left knee pain in August 1983. The examiner also noted that the Veteran denied having any problems with his knees during his October 1983 separation examination. The Veteran described the right knee injury as a direct blow to the knee, and not a twisting injury. Physical examination revealed that the Veteran was not in acute pain and walked briskly without a limp. The Veteran was able to walk on his toes and heels. There were no signs of inflammation and no swelling, redness, heat, tenderness, or effusion. Range of motion in both knees was from 0 degrees to 130 degrees. Repetitive performance did not revealed any evidence of pain, fatigue, weakness, lack of endurance, instability, or incoordination. There was no additional loss of joint function. Good stability in both the mediolateral and anteroposterior planes was observed. Some crepitation and snapping was noted, but these were not painful. The examiner stated that there was documented evidence of one episode of problems in each knee. For the right knee, the examiner noted that the injury was direct, and not a twisting-type injury. The examiner stated that a fracture or local contusion would be expected, but that there was no evidence of any such findings. The examiner stated that the meniscal abnormality shown on magnetic resonance imaging was more of a degenerative variety than due to direct trauma. The examiner also observed that there was no continuity of symptomatology and that the Veteran's post-service work was moderately stressful and required him to be on his feet often. The examiner diagnosed the Veteran with mild bilateral degenerative joint disease and stated that it was less likely than not that the Veteran's current knee problems were caused by or aggravated by the in-service injuries. In a June 2011 addendum report the examiner noted that radiographic imagery was compatible with those diagnoses. In an October 2012 statement, the Veteran reported that he had been diagnosed with degenerative joint disease and that he never had any problem with his knee prior to his period of service. After a thorough review of the entirety of the evidence of record the Board finds that there is a preponderance of evidence against the Veteran's claims and that entitlement to service connection for right and left knee disabilities is not warranted. To establish service connection for the claimed disability on a direct basis, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the two. The Veteran's claim of entitlement to service connection for bilateral knee disabilities fails due to the lack of a nexus between a current disability and an in-service incurrence or injury. While the record shows that the Veteran injured his knees in service, post-service medical records, including the VA examination reports from November 2005 and May 20011, indicate that the Veteran's current knee disabilities are unrelated to his period of service. Those reports include thorough reviews of the evidence and well-reasoned medical opinions from trained medical professionals. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The Board has considered the Veteran's assertions and acknowledges that he is competent to testify as to symptoms which are non-medical in nature or which come to him through his senses, such as the occurrence of an event or injury in service. However, it has been noted that individuals without training are not competent to provide evidence as to more complex medical questions. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran is not shown to have medical training and expertise, and so cannot provide a competent opinion on a matter as complex as the etiology of his bilateral knee disabilities. Even according the Veteran's assertions some probative value, they are outweighed by the objective medical evidence, which indicates that his knee disabilities are not related to his period of service or any injury therein. Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). A claimant has the responsibility to present and support a claim for benefits under laws administered by the VA. 38 U.S.C.A. § 5107(a) (West 2002). The Veteran was advised of the need to submit medical evidence of the existence of the disabilities claimed and a relationship between those disabilities and the Veteran's period of service. The most persuasive and probative evidence of record fails to demonstrate that the Veteran's knee disabilities are related to his period of service or any injury therein. In sum, the Board finds that there is a preponderance of evidence against a grant of service connection for bilateral knee disability. As there is a preponderance of evidence against the claim, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Tympanic Membrane Perforation The Veteran has claimed entitlement to a compensable rating for his service-connected residuals of a perforated right tympanic membrane. While a Veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established, and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Separate ratings can be assigned for separate periods of time based on the facts found. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. Ap. 119 (1999). The relevant evidence of record was laid out in detail above, in the section pertaining to the Veteran's claims of entitlement to service connection for right ear hearing loss and a non-hearing loss right ear disability. In this case, the 0 percent disability rating was assigned under 38 C.F.R. § 4.87, Diagnostic Code 6211. Under Diagnostic Code 6211, perforation of the tympanic membrane warrants a 0 percent (noncompensable) rating. Therefore, a compensable rating is not available for tympanic membrane perforation under Diagnostic Code 6211. The Veteran may only receive a higher rating under a different diagnostic code for diseases of the ear. However, based on a review of the evidence does not show any other Diagnostic Code that might be the basis for a compensable rating. 38 C.F.R. § 4.87, Diagnostic Codes 6200-6210 (2012). There is no evidence of chronic suppurative otitis media, mastoiditis, cholesteatoma, chronic nonsuppurative otitis media with effusion, otosclerosis, Meniere's syndrome, loss of auricle, malignant neoplasm of the ear, benign neoplasm of the ear, or chronic otitis externa. Therefore, those Diagnostic Codes cannot be applied, and the Veteran's history of a tympanic membrane perforation must continue to be rated as noncompensable under Diagnostic Code 6211. Butts v. Brown, 5 Vet. App. 532 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). With regard to Diagnostic Code 6260, for tinnitus, the Board notes that issue has already been referred to the RO for further development. Similarly, the Board notes that the Veteran's claim asserting entitlement to service connection for vertigo as secondary to his service-connected history of a perforated tympanic membrane, for which a compensable rating is possible under Diagnostic Code 6204, has also been referred to the RO for further development. Accordingly, the Board finds that entitlement to a compensable rating for the Veteran's service-connected residuals of a tympanic membrane perforation must be denied. In so finding, the Board adds that there is no evidence that any tympanic membrane perforation has exceeded the current rating assigned at any time during the period on appeal. Therefore, there is no basis for any staged rating. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. Ap. 119 (1999). Finally, the Board notes that there is no evidence of exceptional or unusual circumstances to warrant referring the case for extra-schedular consideration. 38 C.F.R. § 3.321(b)(1) (West 2002). The Board finds no evidence that the history of a right tympanic membrane perforation has markedly interfered with his ability to work. While the Veteran has asserted that his hearing capabilities interfere with his ability to work, the Board has denied service connection for right ear hearing loss, finding that it is not related to the right tympanic membrane perforation. In sum, the Board has determined that the preponderance of the evidence is against the Veteran's claim of entitlement to a compensable rating for residuals of a perforated right tympanic membrane. Since the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Duty to Assist The Board is required to ensure that the VA's duty to notify and duty to assist obligations have been satisfied. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The notification obligation in this case was met by letters from the RO to the Veteran dated in February 2005, September 2005, and May 2011. Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006); Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The RO also provided assistance to the Veteran as required, as indicated under the facts and circumstances of this case. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). In addition, the Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal and has not argued that any errors or deficiencies in the accomplishment of the duty to notify or the duty to assist have prejudiced the Veteran in the adjudication of his appeal. The Veteran has been afforded a VA examination on the issues under review during the course of his appeal. The report from that examination shows that the examiner reviewed the Veteran's medical records, recorded his current complaints, conducted an appropriate physical examination and rendered diagnoses and opinions consistent with the remainder of the evidence of record and pertinent to the rating criteria. Barr v. Nicholson, 21 Vet. App. 303 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, VA met the duty to assist. ORDER Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for a right ear disability, to include otitis media and chronic Eustachian tube blockage, is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to a compensable rating for the Veteran's service-connected residuals of a perforated right tympanic membrane is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs