Citation Nr: 1301366 Decision Date: 01/14/13 Archive Date: 01/23/13 DOCKET NO. 10-38 088 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for erectile dysfunction. 2. Entitlement to service connection for a bilateral hearing loss disability. 3. Entitlement to service connection for tinnitus. 4. Entitlement to service connection for a right knee disability. 5. Entitlement to service connection for a left knee disability. 6. Entitlement to service connection for a thoracolumbar spine disability. REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD C. R. Olson, Counsel INTRODUCTION The veteran served on active duty from February 1969 to February 1971 and from April 2005 to June 2006. He also had periods of inactive duty training and active duty for training as a member of the National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. The Veteran does not have erectile dysfunction as the result of a disease or injury incurred or aggravated during his active service. 2. A bilateral hearing loss disability was not present during the Veteran's first period of active service. 3. A sensorineural hearing loss was not manifested to a degree of 10 percent or more within the first year after the Veteran completed his active service. 4. A bilateral hearing loss disability existed prior to the Veteran's second period of active service, was noted when he was examined and accepted for service, and did not increase in severity during that period of active service. 5. The Veteran does not have a bilateral hearing loss disability as the result of disease or injury incurred or aggravated during either period of active service. 6. The Veteran does not have tinnitus as the result of disease or injury incurred or aggravated during either period of active service. 7. Tinnitus was not manifested to a degree of 10 percent or more within the first year after the Veteran completed his active service. 8. The Veteran's right knee patellofemoral syndrome with arthritis is presumed to have been incurred during his active wartime service. 9. The Veteran's left knee patellofemoral syndrome with arthritis is presumed to have been incurred during his active wartime service. 10. The Veteran does not have a thoracolumbar spine disability as the result of disease or injury incurred or aggravated during his active service. 11. Arthritis of the thoracolumbar spine was not manifested to a degree of 10 percent or more within the first year after the Veteran completed his active service. CONCLUSIONS OF LAW 1. The criteria for the award of service connection for erectile dysfunction have not been met. 38 U.S.C.A. §§ 101(16), 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The criteria for the award of service connection for a bilateral hearing loss disability have not been met. 38 U.S.C.A. §§ 101(16), 1101, 1110, 1112 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.306, 3.309 (2012). 3. The criteria for the award of service connection for tinnitus have not been met. 38 U.S.C.A. §§ 101(16), 1101, 1110, 1112 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 4. The criteria for the award of service connection for patellofemoral syndrome with arthritis of the right knee have been met. 38 U.S.C.A. §§ 101(16), 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 4.59 (2012). 5. The criteria for the award of service connection for patellofemoral syndrome with arthritis of the left knee have been met. 38 U.S.C.A. §§ 101(16), 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 4.59 (2012). 6. The criteria for the award of service connection for a thoracolumbar spine disability have not been met. 38 U.S.C.A. §§ 101(16), 1101, 1110, 1112 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the Veteran's claims file and Virtual VA file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Consequently, the following discussion will be limited to the evidence the Board finds to be relevant. The Veteran 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 Board specifically finds that any evidence not discussed does not support the claims. In order to establish service connection, three elements must be established. There must be medical evidence of a current disability; medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and competent evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 U.S.C.A. §§ 101(16), 1110 (West 2002); 38 C.F.R. § 3.303 (2012); see also Hickson v. West, 12 Vet. App. 247, 253 (1999). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b) (2012). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d) (2012). The Veteran's service personnel records confirm his receipt of the Purple Heart medal, which establishes his participation in combat. Pursuant to 38 U.S.C.A. § 1154(b), 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). 38 U.S.C.A. § 1154(b), however, 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). 38 U.S.C.A. § 1154(b) does not establish service connection for a combat veteran; it aids him or her by relaxing the adjudicative evidentiary requirements for determining what happened in service. See Wade v. West, 11 Vet. App. 302, 305 (1998) (holding that "a combat veteran who has successfully established the in-service occurrence or aggravation of an injury pursuant to § 1154(b), must still submit sufficient evidence of a causal nexus between that in-service event and his or her current disability"). A veteran (or in this case, the appellant) must still generally establish the 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). Erectile Dysfunction There is no competent evidence of erectile dysfunction during either period of active service. Following the Veteran's return from Southwest Asia, he was examined in August 2006 and his external genitalia were normal. The Veteran was seen at a military medical facility, in October 2006, for complaints of wrist and knee pain. There were no genitourinary symptoms with urination, incontinence or discharge. The assessment included male erectile disorder. It was noted that the Veteran was on Viagra and had tried Cialis. He would try Levitra. Certain chronic diseases may be presumed to have been incurred during active military service if manifest to a degree of 10 percent or more within the first year following active service. 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). These presumptive chronic diseases do not include erectile dysfunction. Subsequent records from the military clinic listed male erectile disorder as one of the Veteran's problems but did not indicate that it was incurred or aggravated by service. The Veteran's claim for service connection was received in January 2009. This included claims for service connection for hypertension and for erectile dysfunction secondary to hypertension. Service connection may be granted for a disability which is proximately due to and the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). This would include the extent of any aggravation of any otherwise non-service-connected disability. 38 C.F.R. § 3.310(b) (2012); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). Secondary service connection requires competent evidence of a nexus with a service-connected disability. See Reiber v. Brown, 7 Vet. App. 513 (1995). An appellant's own conclusion, stated in support of his claim, that his present disability is secondary to his service-connected disability is generally not competent evidence as to the issue of medical causation. See 38 C.F.R. § 3.159 (2012); see also Grivois v. Brown, 6 Vet. App. 136 (1994). The Board acknowledges the Veteran's competency to testify regarding such observable symptomatology as erectile dysfunction. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Board concludes, however, that establishing an etiological link between the Veteran's erectile dysfunction and an in-service disease or injury, or a service-connected disability, requires specialized medical knowledge and is outside the scope of lay observation. As such, the Veteran's lay testimony therein lacks probative weight. The Veteran had an examination for erectile dysfunction in May 2009. He reported that the condition had its onset in 1999. There was a gradual onset. It was progressively worse. Dysfunction was not complete. He still had morning erections. He tried Viagra, which worked fine. He was switched to Levitra, which gave him headaches. There was no history of trauma or neoplasm to the genitourinary system. There were no general systemic symptoms due to genitourinary disease. There was no urgency, weak or intermittent stream, dysuria, dribbling, straining to urinate, hematuria, urine retention, urethral discharge, renal colic, or urinary discharge. There was hesitancy/difficulty starting the stream. Daytime voiding was every three hours. Nocturia was three times nightly. There was no history of recurrent urinary tract infection, obstructed voiding, urinary tract stones, renal dysfunction, renal failure, acute nephritis, hydronephrosis, or cardiovascular symptoms. Examination disclosed an enlarged prostate, right and left hydroceles, and a 5 millimeter epidyidymal head cyst. It was noted that a sonogram showed the bilateral hydroceles and epidyidymal cyst. The diagnosis was erectile dysfunction. The examiner expressed the opinion that it was at least as likely as not that the Veteran's erectile dysfunction was caused by or a result of his hypertension. It was explained that, in the United States, greater than 70 percent of males with hypertension had some degree of erectile dysfunction. The correlation between high blood pressure and erectile dysfunction increased with the severity of the high blood pressure. The Veteran was currently on three medications to control his blood pressure, underscoring the increasing difficulty to control it. The physician concluded that it would be more than likely that the Veteran's hypertension was the etiology of his erectile dysfunction. It was commented that the Veteran was slightly hypogonadic with normal total testosterone and low free bioavailable testosterone which might contribute to his erectile dysfunction to a degree yet to be determined by further testing. In September 2009, the RO denied service connection for various conditions, including hypertension and erectile dysfunction. It was explained that the National Guard records showed hypertension was diagnosed in 1997 and treatment begun in 1999. Blood pressure was 136/86 on entry to active service and 136/68 on separation examination. Therefore, the condition existed before service and did not increase in severity during service. Service connection was also denied for erectile dysfunction because it was not manifested during the Veteran's active service. The Veteran did not perfect an appeal of the denial of service connection for hypertension. Conclusion There is no competent evidence to link the Veteran's erectile dysfunction to his active service. He reports it began before service and has been progressively getting worse. A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Here, there is no competent evidence of an increase in disability during his active service. The Veteran has asserted that his erectile dysfunction was due to his hypertension and the VA examiner agreed, but the hypertension itself is not service-connected, so the erectile dysfunction cannot be service-connected on a secondary basis. In this case, the medical records provide a preponderance of evidence showing that the Veteran's erectile dysfunction was not incurred or aggravated during any period of his active service and that it is not proximately due to or the result of a service-connected disability. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable and the appeal must be denied. 38 U.S.C.A. § 510 7(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Bilateral Hearing Loss Disability and Tinnitus What constitutes a hearing loss disability for VA purposes is defined by regulation. For the purposes of applying the laws administered by VA, 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. 38 C.F.R. § 3.385 (2012). The Veteran has emphasized his combat service in Vietnam and the associated noise as the cause of his hearing loss disorder and tinnitus. However, the service treatment records for that period of active service do not show any hearing loss or disease or injury of his ears. Audiometric examinations on entrance in February 1969 and separation in January 1971 did not show any abnormalities or defects in hearing acuity, and the examiners found the Veteran's ears and drums to be normal. The Veteran had several examinations for National Guard service. In August 1980, his ears and drums were normal. Audiologic evaluation showed the following pure tone thresholds, in decibels, which are within normal limits: HERTZ 500 1000 2000 3000 4000 RIGHT 00 05 05 10 10 LEFT 05 05 10 15 15 On periodic examination, in October 1984, the Veteran's ears and drums were normal. Audiologic evaluation showed the following pure tone thresholds, in decibels, which are within normal limits: HERTZ 500 1000 2000 3000 4000 RIGHT 00 05 05 10 10 LEFT 05 05 10 15 15 These 1980 and 1984 examinations are further evidence that the Veteran's first period of active service did not result in a hearing loss disorder at that time. The first evidence of a hearing loss came on the November 1988 examination. Again, the Veteran's ears and drums were normal. Audiologic evaluation showed the following pure tone thresholds, in decibels, which reflect a hearing loss in the right ear: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 5 0 5 30 55 50 LEFT 5 0 5 20 20 25 On quadrennial examination in April 1994, the Veteran's ears and drums were normal. However, audiologic evaluation confirmed a right ear hearing loss with the following pure tone thresholds, in decibels: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 10 0 10 40 60 50 LEFT 5 0 10 20 30 30 Hearing conservation data for December 1994 were similar with pure tone thresholds, in decibels: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 0 0 10 30 60 60 LEFT 15 0 10 20 15 25 On examination in March 1996, the Veteran's ears and drums were again found to be normal. Pure tone thresholds, in decibels were: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 10 0 20 35 40 65 LEFT 15 5 5 25 30 40 On examination in March 2001, the Veteran's ears and drums were again found to be normal. There was a diagnosis of a high frequency hearing loss. Pure tone thresholds, in decibels were: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 10 15 15 50 60 65 LEFT 15 5 5 30 35 45 The Veteran had a hearing loss when he was examined and accepted for his second period of active service. As discussed, above, a preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). In April 2005, the Veteran was examined for active service. He reported having a hearing loss and it was noted that he had a profile for it. Audiometric examination showed that both ears met the regulatory definition for a hearing loss disability. Pure tone thresholds, in decibels were: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 10 5 15 55 60 55 LEFT 10 5 5 30 40 45 The Veteran reports that while serving in Iraq, he was with the Corps of Engineers and was exposed to noise from various equipment including dozers, road graders, backhoes, generators, and dump trucks. The service treatment records for that period do not reflect any additional hearing loss, acoustic trauma, or ear disease or injury. The Board notes that even a lay witness, such as the Veteran, is competent to report exposure to loud noise. However, a lay witness does not have the medical training or experience to determine the effects of the noise exposure or whether it resulted in increased disability. 38 C.F.R. § 3.159(a). Following the Veteran's return from active service, he was afforded an examination in August 2006. His ears and drums were normal. He was noted to have a hearing loss. Audiometric examination showed that both ears met the regulatory definition for a hearing loss disability. Pure tone thresholds, in decibels were: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 10 5 20 55 65 60 LEFT 10 5 5 30 40 45 The records make no mention of tinnitus prior to the April 2009 VA examination. The Veteran had a VA audiometric examination in April 2009. The claims folder was reviewed. It was noted that the Veteran was tested before his recent period of active service and again in August 2006 and that the thresholds did not show significant change in hearing any more than that expected for test/retest differences. The Veteran's noise exposure history was discussed. He had served in the infantry. Most recently, he served one year in Iraq as an engineer. He reported noise exposure to artillery, explosives, power tools, heavy equipment, diesel engines, aircraft and various weapons. As a civilian, he had exposure for home use to lawn equipment, motorcycles, and power tools. He worked in surveying and computer drafting before and after his recent period of active duty. He also used to hunt occasionally but no longer did so. As to tinnitus, he said it began somewhere between 5 to 10 years ago, with gradual onset, so he could not tell the exact time of onset. It was intermittent, not constant. It occurred several times a week, lasting for several minutes each time. On the authorized VA audiologic evaluation in April 2009, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 Average RIGHT 5 5 15 60 60 35 LEFT 5 5 10 35 45 23.75 Speech audiometry revealed speech recognition ability of 98 percent in the right ear and of 98 percent in the left ear. Otoscopy and tympanometry were normal, bilaterally. The examiner concluded that the pure tone and speech testing indicated a high frequency sensorineural hearing loss and good word recognition in quiet. The diagnosis was bilateral high frequency sensorineural hearing loss and bilateral recurrent tinnitus. The examiner expressed the opinion that the hearing loss and tinnitus were not permanently aggravated by military noise. She explained that the Veteran's hearing thresholds did not significantly change from the time of activation to the time of separation. With regards to his tinnitus, he reported that it was present prior to the most recent active duty period and did not report significant worsening during active duty. The examiner also expressed the opinion that it was likely that the Veteran's hearing loss and tinnitus might be due to his National Guard service based on his decreased hearing during National Guard service and documented by National Guard audiograms from 1988 to 2003. The Board notes that VA pays benefits based on disease or injury during active Federal Service and simply being a member of the National Guard at the time of the onset of a disability does not qualify for the benefits based on service-connected disability. See 38 U.S.C.A. §§ 101(21), 1110. In June 2010, a VA audiologist reviewed the service treatment records and National Guard records and expressed the opinion that the Veteran's hearing loss was less likely than not caused by or a result of military noise exposure because the hearing thresholds did not significantly worsen from the time of activation to the Veteran's release from active duty. Conclusion A lay witness is competent to report noise exposure during service. However, as a lay witness, he is not competent to determine that such noise exposure resulted in permanent injury or caused the permanent worsening of a preexisting condition. In this case, there is no competent medical evidence of onset or worsening during either period of active service. The service treatment records, including entrance and separation examinations for the first period of active service do not show the presence of relevant disease or injury or of a hearing loss or tinnitus during the Veteran's first period of active service. Audiometric testing in 1980 and 1984 confirmed normal hearing. Thus, the preponderance of evidence shows that despite some noise exposure during the first period of service, there was no hearing loss. The Board acknowledges that service connection may still be awarded for a hearing loss disorder despite the fact that audiometric findings do not meet the definition for hearing loss as defined by VA at 38 C.F.R. § 3.385 if the evidence of record otherwise establishes a nexus between any current hearing loss and a disease, injury, or other incident of service. See Hensley v. Brown, 5 Vet. App. 155 (1993). In the present case, however, VA examiners did not find that any current hearing loss disorder was related to the Veteran's in-service noise exposure. Subsequent periodic audiometric testing for continued National Guard service documented the progression of a hearing loss during the Veteran's civilian work life. The Veteran was called to active Federal service for a year in Iraq, during which time he had noise exposure related to construction activities. However, audiometric examinations before and after this period of active service showed no significant change. That is, the pre-service hearing loss was noted when the Veteran was examined and accepted for service and there was no increase in the severity of the hearing loss (or aggravation) during service. There is no record of tinnitus during either period of active service. The Veteran's recollection of intermittent tinnitus, almost three years later, is not sufficient to establish that the condition existed before service or that it became worse during service. While the Veteran is competent to report noise exposure during his active service and his report of noise exposure is credible, it is not sufficient to establish that a hearing loss or tinnitus were incurred or aggravated during either period of service. The medical records and medical opinion based on examination of the Veteran and review of his records forms the preponderance of evidence on these claims. Since the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not applicable and the appeal must be denied. 38 U.S.C.A. § 510 7(b); Gilbert; Ortiz. Right and Left Knee Disabilities The Veteran contends that he incurred knee disabilities during his active service. He reports that during his first period of active service, he served in an air assault capacity, jumping as much as 15 feet from helicopters with a rucksack, M60 machine gun, and 500 rounds of ammunition. He states that while deployed in Iraq, he carried about 70 pounds of equipment and was treated for knee symptoms. The service treatment records for the first period of service do not reflect any knee problems. The Veteran's lower extremities were normal when he was examined for service in February 1969 and on separation examination in January 1971. Examinations for National Guard service show normal lower extremities on examinations in August 1980, October 1984, November 1988, April 1994, March 1996, and March 2001. The examination reports do not reflect any knee complaints, findings or diagnoses. The normal findings on separation from the first period of service and on examinations for many years thereafter are significant evidence against a knee disability beginning during the Veteran's first period of active service. On examination for active service, in April 2005, the Veteran reported no knee trouble. On physical examination, his lower extremities were normal. The records do not document knee symptoms or treatment during the second period of active duty. On examination in August 2006, the Veteran did report right knee pain with running. However, the examiner reported normal lower extremities. The Veteran again reported a knee problem on examination in September 2006 and the examiner indicated possible arthritis in the right knee. The Veteran was seen at a military medical facility, in October 2006, for complaints of wrist and knee pain. He complained of intermittent knee pain, worse with running and sitting for long periods. There was no history of trauma or injury. Examination of the knees revealed abnormalities with crepitance. There was a normal range of motion and no pain. The assessment was osteoarthritis. X-rays studies of the right knee were considered to be unremarkable. When the Veteran was seen at the military medical facility, in January 2007, his problem list included patellofemoral syndrome and osteoarthritis. The Veteran had a VA joints examination in May 2009. The claims file was reviewed. The Veteran reported the intermittent onset of bilateral knee pain, which became markedly worse while serving in Iraq in 2005. He said he was given medication and a profile for no running. He said his knees continued to bother him. It was hard to arise from a squatting position, stairs were problematic, and walking a mile caused pain the next day. The course was progressively worse. He also reported giving way, pain, stiffness, and limitation of joint motion. Examination disclosed an antalgic gait. The right and left knees had crepitus and tenderness, clicks or snaps, grinding, and subpatellar grinding and snapping. Motion of both knees was measured. May 2009 X-ray studies were reviewed. Arthritic changes were noted within the bilateral tricompartments. The impression was arthritic changes. The May 2009 VA examination concluded with a diagnosis of patellofemoral syndrome bilateral knees. There was no opinion as to service connection. X-ray studies of the knees, at the military medical facility in October 2009, disclosed subtle osteoarthritic changes affecting the medial tibial small compartments. The Veteran returned to the military medical facility, in April 2011 with a complaint that both knees, mainly the left knee, had been giving him more trouble. The left knee had tenderness and crepitus. Previous X-ray studies were reviewed. The assessment was osteoarthritis. Conclusion Arthritis may be presumed to have been incurred during active military service if it is manifest to a degree of 10 percent or more within the first year following active service. 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Arthritis may be clearly manifested by degenerative changes seen on X-rays. But that is not the only way it can be manifested. The regulations recognize that arthritis may be manifested by symptoms such as pain and crepitation. Further, these symptoms are recognized as being entitled to at least the minimal compensable rating - 10 percent. See 38 C.F.R. § 4.59. We now have X-ray confirmation of osteoarthritic changes in both knees as early as October 2006, and within a year after the Veteran completed his second period of active service, a doctor diagnosed osteoarthritis in the knees. Moreover, at that time the doctor found crepitus, which would warrant a 10 percent rating. Thus, the Veteran's bilateral knee arthritis may be presumed to have begun during his active service. With consideration of the diagnosis on VA examination, the Board grants service connection for a patellofemoral syndrome of both right and left knees with arthritis. Thoracolumbar Spine Disability The Veteran contends that he has a thoracolumbar spine disability as the result of injury while serving in Vietnam during his first period of active service. He reported jumping from helicopters, as high as 15 feet from the ground, with a rucksack, M60 machine gun, and 500 rounds of ammunition. He also reports an incident when going down a steep slope with his equipment, he slid and hit his tail bone. The service treatment records do not document any back injury during the Veteran's first period of service. On separation examination, in January 1971, the Veteran's spine was normal. The Veteran had several examinations for National Guard service. There were no back complaints and his spine was reported to be normal in August 1980, October 1984, November 1988, April 1994, March 1996, and March 2001. Notes from a private chiropractor reflect treatment for low back symptoms from September 2003 to April 2010. There is no indication that the symptoms began during the Veteran's initial period of active service. There is no indication that the symptoms increased during the second period of service. Of particular significance is a note dated in early June 2007, indicating the Veteran was back from Iraq and doing well. A note dated later in June 2007 described the Veteran's low back symptoms as mild. In April 2005, the Veteran was examined for active service. He indicated on his report of medical history that he did not have a recurrent back pain or any back problem. The examiner found the Veteran's spine was normal. There is no documentation of any back injury or disease during the second period of active service. On examination in August 2006, there were no back complaints and clinical evaluation of the spine was normal. Outpatient treatment notes from a military medical facility show the Veteran was seen for knee complaints in October 2006 but there were no back complaints until October 2009. The October 2009 clinical record shows there was tenderness to percussion of the paraspinal muscles at the L5 level, right greater than left. Otherwise, there were no clinical abnormalities. The assessment was backache: chronic mid and low back pain with unremarkable examination. Review of the X-ray studies led to impressions of chronic mid and low back pain at level of T7/T8 without radicular symptoms. The October 2009 X-rays of the thoracic spine showed normal alignment. There were degenerative changes of the anterior and plates with osteophyte formation. There were no acute fractures or subluxations. Soft tissues were unremarkable. The October 2009 X-rays of the lumbosacral spine revealed very slight right convexity scoliotic deformity centered at approximately L3. End plate degenerative changes were noted with osteophyte formation affecting the third to fifth vertebral bodies. Disc space narrowing was noted at the L5-S1 level. The Veteran was seen at the military medical clinic in August 2010 for multiple issues. He said he was having some mid to lower back pain. It started between his shoulder blades and went down. There were times when he had numbness in his hands and tingling in his feet. He thought the symptoms were from a fall back in 1969. He said that since then, it seemed like his back would get tight and get out of place. There were no relevant findings. There was a diagnosis of osteoarthritis, but it was not clear whether this referred to the Veteran's knees or his back. There was no comment as to the Veteran's claim of symptoms from an injury in 1969. There was no comment as to a relationship between the current symptoms and the claimed injury in service. Conclusion The Veteran reports that he sustained a fall during his first period of service and landed on his tail bone. As a lay witness, he is competent to report an injury in service, and his account is consistent with the circumstances of his service. See also 38 U.S.C.A. § 1154(b). Nevertheless, injury alone is not sufficient to establish service connection. It is not enough to show injury during service, there must currently be a residual disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There must be a current disability. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). In August 2010, the Veteran told a clinician at a military medical clinic that he had back symptoms since an injury in service. As a lay witness, the Veteran is competent to report what he actually experienced. 38 C.F.R. § 3.159. However, in this case, the numerous medical examination reports made on separation examination in 1971 and periodically over the years in the 1980's and 1990's establish by a preponderance of evidence that the Veteran did not have continuing back symptoms since his first period of active service. The Board finds no credible evidence linking the Veteran's current back disorder to any disease or injury during either period of active service. On this point, the separation examinations provide the preponderance of credible evidence and show that the Veteran's spine was normal at both times when he was released from active service. Further, unlike the knees, there is no competent evidence of arthritis of the spine during the first year after the Veteran completed his active service. There is no basis in law for the Board to presume that the current mild arthritic changes in the spine began during the Veteran's active service. Moreover, there is no competent medical opinion linking the current arthritic changes of the spine to service or to any incident in service. On this issue, we have the Veteran's claim that he had a fall in service, which is credible, but not sufficient by itself to establish service connection. There is no medical opinion or other competent evidence connecting the current back disability to either period of active service. There is a single statement by the Veteran to a service department clinician to the effect that he has been symptomatic since the incident. That statement is greatly outweighed by the separation examinations and other periodic examinations for service, which establish by a preponderance of evidence that there were no residuals. In as much the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable and the appeal must be denied. 38 U.S.C.A. § 510 7(b); Gilbert; Ortiz. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA) and subsequent legislation, VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). In a letter dated in January 2009 the RO provided the Veteran with an explanation of the type of evidence necessary to substantiate his claim, as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. The January 2009 letter also provided notice regarding potential ratings and effective dates. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The initial notice letter was provided before the adjudication of his claim in September 2009. VA has complied with the notice requirements of VCAA and has no outstanding duty to inform the appellant that any additional information or evidence is needed. Therefore, the Board was able to decide the appeal without a remand for further notification. The Board also finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. The Veteran's service medical records have been obtained. His available post-service treatment records have also been obtained. The Veteran has had a VA examinations and a medical opinion has been obtained. He has declined the offer of a hearing. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Entitlement to service connection for erectile dysfunction is denied. Entitlement to service connection for a bilateral hearing loss disability is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for patellofemoral syndrome with arthritis of the right knee is granted. Entitlement to service connection for patellofemoral syndrome with arthritis of the left knee is granted. Entitlement to service connection for a thoracolumbar spine disability is denied. ______________________________________________ T. D. JONES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs