Citation Nr: 1314060 Decision Date: 04/29/13 Archive Date: 05/15/13 DOCKET NO. 09-40 367 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) with depression. 2. Entitlement to service connection for a right foot skin disorder. 3. Entitlement to service connection for a left foot disorder, to include a skin disorder. 4. Entitlement to service connection for hearing loss of the right ear. 5. Entitlement to service connection for a right knee disorder. 6. Entitlement to service connection for a left knee disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran had active service from November 1966 to November 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009, rating decision by a Department of Veterans Affairs (VA), Regional Office (RO), that denied the benefits sought on appeal. The Board notes that the Veteran has been diagnosed with PTSD, in addition to other psychiatric disorders. The scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, the Board has characterized that issue as set forth above. A rating decision in May 2012 granted the Veteran's claim for service connection for left ear hearing loss. The Veteran has not disagreed with the rating or effective date assigned, thus that matter is not on appeal. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. The evidence of record is at least in equipoise as to whether the Veteran's psychiatric disorder, to include PTSD with depression, is due to active service. 2. Resolving all doubt in the Veteran's favor, a right foot skin disorder is related to his active service. 3. Resolving all doubt in the Veteran's favor, a left foot skin disorder is related to his active service. 4. The Veteran is not shown to have a right ear hearing loss disability for VA compensation purposes. 5. A right knee disorder is not shown to have had onset during service; arthritis of the right knee was not manifest to a compensable degree within one year of separation from service; and a right knee disorder, first documented after service, is not shown to be related to any injury, disease, or event of service origin. 6. A left knee disorder is not shown to have had onset during service; arthritis of the left knee was not manifest to a compensable degree within one year of separation from service; and a left knee disorder, first documented after service, is not shown to be related to any injury, disease, or event of service origin. CONCLUSIONS OF LAW 1. The criteria for service connection for a psychiatric disorder, to include PTSD with depression, have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. The criteria for service connection for a right foot skin disorder have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 3. The criteria for service connection for a left foot skin disorder have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 4. The criteria for service connection for hearing loss of the right ear have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 303, 3.307, 3.309, 3.385, 4.85, 4.86 (2012). 5. The criteria for service connection for a right knee disorder have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 6. The criteria for service connection for a left knee disorder have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claims submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The notice requirements were accomplished in letters sent July 2008 and November 2008. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006). The letters also provided notice of the type of evidence necessary to establish a disability rating or effective date for the claimed disability under consideration, pursuant to the recent holding in Dingess v. Nicholson, 19 Vet App 473 (2006). Thereafter, the claims were readjudicated in the May 2012 Supplemental Statement of the Case. The claimant was provided the opportunity to present pertinent evidence. The service treatment records, Virtual VA file, and available private and VA treatment records have been obtained. Following the Board's February 2011 remand, the agency of original jurisdiction made appropriate efforts to obtain copies of any outstanding service treatment records to specifically include examination reports relating to an August 1980 X-ray, with no new records obtained. A Formal Finding of Unavailability was issued in March 2012 explaining that the National Personnel Records Center (NPRC) provided a negative response in December 2010, indicating that the Veteran's service treatment records had been provided to the RO in April 2002. The March 2012 Formal Finding of Unavailability certifies that all efforts to obtain additional records described by the Veteran have been exhausted, further attempts would be futile, and that it is believed that all service treatment records have been associated with the claims file. As all appropriate avenues have been exhausted, and further considering the fact that service treatment records from the locations and time periods described by the Veteran appear to be contained in the set available for review, the Board finds no cause to question the formal finding that all service treatment records have been associated with the claims file. The Board finds that the duty to assist has been fulfilled with regard to obtaining the Veteran's service treatment records. In addition, he has been provided with VA examinations, and a Veterans Health Administration (VHA) opinion has been obtained. He has not indicated there are any additional records that VA should seek to obtain on his behalf. Therefore, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claims, and no further assistance to develop evidence is required. Service connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). 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). Moreover, where a Veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis, sensorineural hearing loss, or psychoses, becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). PTSD with Depression The Veteran asserts that he developed a psychiatric disability in service. Specifically, he contends that he developed PTSD with depression due to his experiences during the Vietnam war. In this regard the Veteran reported exposure to hostile fire, to include mortar attacks, while stationed in Vietnam. He also claims to have experienced additional in-service stressors to include witnessing a May 1967 helicopter crash in Vietnam, seeing an old Vietnamese man shot, a January 1968 ammunition dump explosion, seeing fellow service members killed, witnessing enemy soldiers killed by helicopter fire, a March 1967 B-52 strike, and Puff the Magic Dragon gunship firing over his head in August 1967. He now claims these experiences traumatized him. Claims for service connection for PTSD encompass claims for service connection for all psychiatric disabilities that are reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (under the criteria of DSM-IV); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) (2012). VA considers diagnoses of mental disorders in accordance with the American Psychiatric Association: The DSM-IV criteria for a diagnosis of PTSD include: (A) exposure to a traumatic event; (B) the traumatic event is persistently experienced in one or more ways; (C) persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness is indicated by at least three of seven symptoms; (D) persistent symptoms of increased arousal are reflected by at least two of five symptoms; (E) the duration of the disturbance must be more than one month; and (F) the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV). According to the DSM-IV criteria, the traumatic event, or stressor, must involve experiencing, witnessing, or being confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. In addition, the response must involve intense feelings of fear, hopelessness, or horror. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the circumstances, conditions, or hardships of service, lay testimony alone may establish the occurrence of the claimed stressor. 38 C.F.R. § 3.304(f) (2012). When the evidence does not establish that a Veteran is a combat Veteran, his assertions of service stressors are not sufficient to establish the occurrence of such events. Rather, his alleged service stressors must be established by official service record or other credible supporting evidence. 38 C.F.R. § 3.304(f) (2011); Pentecost v. Principi, 16 Vet. App. 124 (2002); Fossie v. West, 12 Vet. App. 1 (1998); Cohen v. Brown, 10 Vet. App. 128 (1997); Doran v. Brown, 6 Vet. App. 283 (1994). If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD, and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. Fear of hostile military or terrorist activity means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f)(3) (2012). After a careful review of the evidence of record, the Board finds that it is at least as likely as not that the Veteran's PTSD with depression is related to service. A Veteran is competent to testify to factual matters of which he had first-hand knowledge. Lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the personal knowledge of the witness. The Board finds that the Veteran is competent to describe symptoms of sadness and anxiety. See Jandreau, 492 F.3d 1376-77; 38 C.F.R. § 3.159(a)(2) (2012). The Veteran's service personnel records show that he served in Vietnam from April 1967 to April 1968. He served with the 21st Svc & Sup Co APO SF 96321 and his principal duty was listed as laundry worker. He participated in the Vietnam Counteroffensive Phase II campaign in August 1967. The Veteran's Armed Forces Of The United States Report Of Transfer Or Discharge (DD Form 214) listed his military occupational specialty as smoke and flame specialist. He was awarded the National Defense Service Medal, Vietnam Service Medal, Vietnam Campaign Medal, One Oversea Bar, and Marksman (Riffle M-14). The Veteran's service medical records are negative for any complaints or clinical findings of psychiatric problems. After service, private treatment records show that in 2008 the Veteran was hospitalized for complications related to PTSD associated with his Vietnam service. A March 2008 clinical treatment note showed treatment with antidepressants. In April 2008 a VA psychiatrist diagnosed dysthymia and a subsequent treatment record in May 2008 noted a diagnosis of PTSD. A VA psychological consultation report in August 2008 noted the Veteran's complaints of depression and survivor's guilt related to his service in Vietnam. Following an evaluation of the Veteran, the psychologist diagnosed anxiety disorder, chronic PTSD, addictive disorder and alcohol abuse. Accordingly, private and VA treatment records etiologically related the Veteran's psychiatric complaints to stressors to which he was reportedly exposed while stationed in Vietnam. In support of his alleged Vietnam stressors, the Veteran submitted a written statement in October 2011 from C.R., a service member who served with the Veteran in Vietnam, who reported that while they initially served 6 months in Phan Rang, Vietnam, they were subsequently sent to Betty in Phan Tiet in October 1967. During the time they were both stationed in Phan Tiet, Vietnam, they were continually exposed to mortar and sniper fire, as well as rocket attacks. The Veteran underwent a VA mental health disorders examination in February 2011. He reported a nervous breakdown following an incident that occurred in 2008 after being treated for a total knee replacement. He noted that he had served in a war zone during the Vietnam War although he did not serve in combat. The Veteran related coming under mortar attack. He also related witnessing a helicopter crash, witnessing the injuries and death of others, and being threatened with personal injury or death. The examiner noted that the Veteran responded with intense fear and feelings of helplessness. He had felt horror and was stunned or in shock by the traumatic events to which he was exposed. He described feeling fearful and terrified. The diagnosis was PTSD, alcohol abuse, depression not otherwise specified, and rule out dementia. The examiner determined that the Veteran met the criteria for Axis I diagnosis of PTSD because he was exposed to a traumatic event that involved actual death, threatened death, serious injury, threat to the physical integrity or self or other. The Veteran had responded with intense fear, helplessness and horror. The examiner found that the Veteran's PTSD was not related to fear of terrorism. The February 2011 medical opinion is of great probative value. The opinion was rendered after a review of the claims file, to include the service records, and post-service private treatment records, and cited to the medical evidence in the claims file. It is also consistent with the evidence of record. More importantly, a rationale in support of the opinion was provided. Additionally, there is no competent evidence of record that contradicts the opinion. In fact, the only other evidence of record that addresses the etiology of the Veteran's psychiatric condition, the private and VA medical treatment notes, which for the most part associate the Veteran's PTSD to his reported in-service stressors, which are consistent with the circumstances of the Veteran's service. Therefore, the Board finds that claim of entitlement to service connection for PTSD with depression is warranted. Considering the credible statements provided by the Veteran and fellow serviceman, and the current findings of PTSD, which the competent medical evidence etiologically links the to the Veteran's experiences while serving in Vietnam, and which have been found to be consistent with the circumstances of the Veteran's service, the Board finds that the balance of positive and negative evidence is in relative equipoise. Resolving all reasonable doubt in the Veteran's favor, the competent and credible medical evidence creates a nexus between the Veteran's current PTSD with depression and service. Therefore, service connection a psychiatric disability is granted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Right and Left Foot Disorders The Veteran asserts that he developed a right and left foot disorder while stationed in Vietnam. Specifically, he claims that he developed a skin condition on his feet while stationed in Vietnam. The disease continued to manifest intermittently throughout the years. After a careful review of the claims file, the Board finds that the pertinent evidence of record indicates that it is at least as likely as not that the Veteran's skin disease of the feet had onset in service. Initially, the Board must assess the Veteran's competence and credibility to assert that the skin disease had onset in service. A Veteran is competent to testify to factual matters of which he had first-hand knowledge. Lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the personal knowledge of the witness. Here the Board finds that the Veteran is credible and competent to report that he experienced skin problems in service, as he was able to visibly observe such problems in service. See Jandreau, 492 F.3d 1376-77; 38 C.F.R. § 3.159(a)(2) (2012). The Veteran's service treatment records show that on separation examination in October 1968, he reported a medical history of skin diseases and foot trouble. The clinical assessment was tinea versicolor. The examiner noted skin disease and foot trouble, fungal infection, contracted in Vietnam. After service, a December 2005 private treatment record noted the Veteran's report of problems with his feet since service in Vietnam. Reportedly, the condition resolved, but periodically, he experienced blisters and vesiculation. A private treatment record in October 2008 noted recurrent right foot tinea pedis. Prior treatment included antifungal medication and corticoids. In November 2008 the Veteran was again treated for right foot dermatitis. In an August 2008 witness statement, the Veteran's former supervisor stated that the Veteran had related having trouble with his feet. The Veterans then proceed to remove his shoes and socks to reveal blisters and fungus on his feet. On VA skin examination in January 2009, the Veteran related onset of right foot dermatitis in Vietnam. He described the condition as intermittent and recurrent, becoming symptomatic during summer. On examination, right foot dermatitis was not found, as such, the examiner opined that the condition was not caused by or a continuation of foot fungus diagnosed in service. In support of the opinion, the examiner noted that post-service treatment records showed few instances of treatment for a right foot skin condition. It is apparent that the examination was limited to the right foot and any left foot complaints were not addressed. In October 2009 the Veteran was diagnosed with dyshidrotic eczema affecting the feet. The Veteran reported a history of right foot plantar fungus since service in Vietnam. He was treated in October 2010 for right foot tinea pedis. As the record shows a currently diagnosed a recurrent bilateral foot skin disorder, and there is competent and credible lay evidence of right foot skin symptomatology during service, the determinative issue is whether these are related. Here, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran's bilateral foot skin disorder is related to his active service. The Board acknowledges that the January 2009 VA examiner concluded that the condition was not caused by or a continuation of foot fungus diagnosed in service because right foot dermatitis was not found on examination. However, the Board highlights that some disorders, such as skin rashes, are subject to periodic exacerbations, which may account for the absence of any reports of skin symptomatology in previous medical records. See generally, Ardison v. Brown, 2 Vet. App. 405, 408 (1994). The Board must resolve all doubt with regards to this issue in favor of the Veteran. Moreover, in reaching his conclusion, the examiner explained that post-service treatment records showed few instances of treatment for a right foot skin condition. As such, it is apparent that the examiner failed to consider the Veteran's credible lay statements regarding the in-service onset and continuity of his foot symptomatology. Moreover, it is apparent that any left foot complaints were not addressed on examination. Given this, the January 2009 VA examiner's conclusion is not fatal to the Veteran's claims. Given the medical and lay evidence of record, the Board is of the opinion that the point of equipoise has been reached in this matter. Thus, even though the medical evidence is negative for a definitive opinion relating the claimed disorder to the Veteran's active service, his competent and credible report as to the onset of his disorder and the diagnosis of a bilateral foot skin disorder, leads the Board to conclude that the evidence is at the very least in equipoise as to whether his right and left foot skin conditions had onset during service. When the evidence for and against the claim is in relative equipoise, by law, the Board must resolve all reasonable doubt in favor of the appellant. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Accordingly, with resolution of doubt in the Veteran's favor, the Board concludes that a grant of service connection for a right and left foot skin disorder is warranted. Further inquiry could be undertaken with a view towards development of the claims so as to obtain an additional medical opinion. However, under the benefit of the doubt rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206 -07 (1994). The Board notes that the medical evidence of record does not establish that the Veteran has any other unspecified right or left foot disorder, other than the skin disorder which is being granted herein, that is manifested as a result of his period of active service. In this regard, there is no evidence of record that arthritis of either the right or left foot had manifested to a compensable degree within one year following discharge from service, and there is no evidence of any other right or left foot disability that is currently manifested as a result of the Veteran's active service. Right Ear Hearing Loss The Veteran asserts that during service, he was exposed to loud noise from gun fire. He maintains that due to such in-service acoustic trauma he developed right ear hearing loss. Service connection for impaired hearing shall only be established when hearing status, as determined by audiometric testing, meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels), over a range of frequencies (in Hertz ). See Hensley v. Brown, 5 Vet. App. 155, 158 (1993). The determination of whether a Veteran has a disability based on hearing loss is governed by 38 C.F.R. § 3.385 (2012). For the purposes of applying the law 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, or 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. See 38 C.F.R. § 3.385 (2012). On induction examination in February 1966, audiological testing showed the puretone thresholds in decibels at the tested frequencies of 500, 1000, 2000, and 4000 Hertz in the right ear were 20, 10, 15, and 5. On separation from service in October 1968 audiological testing showed the puretone thresholds in decibels at the tested frequencies of 500, 1000, 2000, and 4000 Hertz in the right ear were 5, 0, -5 and 0. Accordingly, the service treatment records are negative of any complaints and/or treatment for right ear hearing loss and his in-service audiograms, including the October 1968 separation examination, do not show hearing loss pursuant to 38 C.F.R. § 3.385. A private treatment report in March 2009 noted that the Veteran reported excessive noise exposure during military service. Specifically he stated that he was riding in a truck when a fellow soldier fired a shot that was deafening to the left ear for approximately three days. The clinician indicated that an audiogram demonstrated hearing levels between 25 to 35. The clinician noted mild bilateral hearing loss, although it was noted that the right ear did not test lower than 30 decibels and there were two frequencies at 35 decibels in the left ear. There was no noise notch at 4000 Hertz, as typically seen with acute noise trauma damage. However, the audiogram which the clinician referenced in the report was not included and there is no indication that right ear hearing loss pursuant to 38 C.F.R. § 3.385 was shown. On VA examination in February 2011, the results of puretone thresholds, in decibels, at 500, 1000, 2000, 3000, and 4000 Hertz on the right were 20, 25, 25, 30, and 30, and on the left were 30, 35, 30, 45 and 40. His speech recognition score on the right was 94 in the right ear and 92 in the left. The examiner diagnosed mild right ear sensorineural hearing loss. The examiner noted that the Veteran had normal hearing upon entrance and separation examination. However, as his personnel DD Form 214 listed the Veteran's military occupational specialty as smoke and flame specialist, and given his reports of exposure to gunfire in service, the examiner opined that the Veteran's hearing loss, at least at one or more of the frequencies, was as likely as not incurred in service. The February 2011 examination does not show right ear hearing loss pursuant to 38 C.F.R. § 3.385. The Veteran is competent to describe symptoms of hearing loss, which he can perceive, but hearing loss for the purpose of VA disability compensation is not a condition capable of lay observation because it relies upon audiometric, i.e., diagnostic, testing. Jandreau. Although the Veteran is competent to describe symptoms of hearing loss, the diagnosis and causation require the application of medical expertise to the facts presented, which include the Veteran's history and symptomatology and audiology testing as required. 38 C.F.R. § 3.385 (2012). Therefore, the Board determines that hearing loss disability under 38 C.F.R. § 3.385 for VA compensation is not a simple medical condition that a lay person is competent to identify as a lay person is not qualified through education, training, or experience to interpret audiology testing, and the Board determines that hearing loss is not a simple medical condition. Where the determinative question involves a medical diagnosis, not capable of lay observation or the claimed disability is not a simple medical condition, competent medical evidence is required to substantiate the claim. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis or medical opinion. 38 C.F.R. § 3.159 (2012). In this case, there is no competent evidence of hearing loss in the right ear for VA purposes at anytime either in service or at present. The relevant question at issue is whether the Veteran has a right ear hearing disability at present, as defined by 38 C.F.R. § 3.385, so as to meet the criteria for service connection for defective hearing. The Veteran was examined by VA and the diagnostic findings from the audiological examination in February 2011 failed to show right ear hearing loss for VA compensation purposes. 38 C.F.R. § 3.385. Thus, the findings do not satisfy the criteria for right ear hearing loss for VA purposes. 38 C.F.R. § 3.385. Given the lack of competent diagnostic evidence showing that he has a hearing disability in the right ear at present, as that term is defined in 38 C.F.R. § 3.385, service connection must be denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Right and Left Knee Disorders The Veteran contends that he developed a bilateral knee disability during the performance of his duties in service. Specifically, he claims he has bilateral knee arthritis due to boots worn in service, working in the rain, sleeping on the ground, and working on larks to fill fuel bladders while serving in Vietnam. The Board must assess the Veteran's competence and credibility to assert that his knee disabilities had onset in service. A Veteran is competent to testify to factual matters of which he had first-hand knowledge. The Board finds that the Veteran is competent to report that he had right and left knee pain in service and since service. See Jandreau, 492 F.3d 1376-77; Layno, 6 Vet. App. at 465; 38 C.F.R. § 3.159(a)(2) (2012). To the extent that the Veteran reports continuity of bilateral knee symptomatology since service, the Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, can be competent, despite the lack of contemporaneous medical evidence. Buchanan, 451 F.3d at 1331. 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. Gabrielson v. Brown, 7 Vet. App. 36 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). Here the Board finds that the Veteran's contentions are not credible because they are internally inconsistent, and inconsistent with the evidence of record. The service treatment records contain no complaints, history or findings consistent with a knee disability. On separation from service in October 1968 the Veteran denied a history of locked or tricked knee and the Veteran's lower extremities were clinically evaluated as normal. Accordingly, the Board finds that the service medical records lack the combination of manifestations sufficient to identify a chronic bilateral knee disability, to include arthritis. After service, in June 2005, the Veteran was seen for complaints of bilateral knee pain due to degenerative changes of both knees. The clinician also noted a deformity of the left lower extremity from a prior injury and subsequent surgery. A December 2005 private treatment report recorded a medical history of a broken leg. The clinician also noted a history of problems with knee arthritis, bilaterally, for 10 years. A July 2006, VA bilateral knee X-ray revealed degenerative joint disease. A left knee magnetic resonance imaging (MRI) study in August 2006 showed mild degeneration medial meniscus with moderate degenerative changes in the medial joint compartment, along with mild arthofibrosis in the Hoffa's fat pad. A private treatment record in February 2008 contained a diagnosis of total knee replacement, end stage degenerative joint disease. In March 2008, the Veteran reported a history of chronic knee pain since 2001, along with a history of two left leg fractures incurred when a tree fell on the leg. He had undergone a total left knee replacement in January 2008. A VA treatment report in April 2008 noted a history of a bone fracture right below his recently repaired knee. In an unsigned private statement in December 2008, it was noted that the Veteran had been a patient of that clinic since October 1980. He was seen in December 2008 for a fractured tibia ankle on the left. The Veteran had undergone surgery for left medial mallelous in October 1980 at which time the Veteran exhibited arthritis of the knee. Accordingly, the clinician opined that the Veteran most likely had arthritis prior to that time. In January 2010, the Veteran underwent a left total knee arthoplasty revision. In summary, following service discharge, the next record of treatment for knee problems is dated in 2005. In view of the period without evidence of complaint or treatment for the knees until at least 2005, more than 30 years after service, and the lack of clinical findings relating to either knee until 2005, the Board finds that the evidence is against a finding of a continuity of treatment, which weighs heavily against the claims. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Additionally, as the initial radiographic documentation of degenerative changes of the right and left knees is well beyond the one-year presumptive period for manifestation of arthritis, service connection cannot be established for arthritis of the right or left knee spine on a presumptive basis. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The Board has weighed statements made by the Veteran as to incurrence of a bilateral knee disability during service and continuity of symptoms and finds the current recollections and statements made in connection with a claims for benefits to be of less probative value. As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran. Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007). In considering the statements of the Veteran as to the incurrence of a bilateral knee disability in service and continuity of symptoms, in light of the evidence discussed, the Board finds that they did not present a persuasive history because they contradict each other and other evidence of record. In this regard, the Board notes that following his claim for VA benefits the Veteran reported knee pain that he attributed to the performance of his duties in service. As previously noted, the service treatment records contain no complaints, history or findings pertaining to the knees and on separation from service the Veteran denied a history of locked or ticked knee and his lower extremities were clinically evaluated as normal. Significantly, post-service discharge the medical treatment records do not show any report of trauma to the either knee until many years after service. Specifically, the records reference left lower extremity trauma after 1980's. In this regard, in December 2005 private treatment record noted a medical history of a broken leg and a history of problems with knee arthritis, bilaterally, for 10 years. In March 2008, the Veteran reported a history of chronic knee pain since 2001, along with a history of 2 left leg fractures incurred when a tree fell on the leg. While an unsigned private statement in December 2008, noted that the Veteran exhibited arthritis of the knee in 1980, which more likely developed prior to that time, there is no indication that arthritis was present in service or developed within one year of discharge from service in 1968. The statement is mostly to the effect that the Veteran had knee arthritis prior to 1980, a fact which is not in dispute. Therefore, the Board finds that continuity of symptoms has not been established, either through the competent evidence or through the Veteran's statements. This is because his statements as to incurrence or a right or left knee disability in service with a continuity of symptoms are less persuasive than the service treatment records and the post-service medical evidence. Therefore, the Board finds that continuity of symptomatology has not here been established, either through the competent evidence or through the Veteran's statements, because his statements are not considered credible. In a witness statement in July 2009, T.M. indicated that he had worked with the Veteran for 23 years and had noticed that the Veteran limped and had trouble walking from the first time they met. To the extent that the witness statement is offered as proof of onset of the current bilateral knee disability in service, the Board notes that there is no indication that the witness had any personal knowledge of the Veteran's knee conditions in service or following service discharge. Moreover, the witness statement is mostly to the effect that the Veteran's has exhibited knee problems for many years, a fact which is not in dispute. On the question of medical causation, medical evidence of an association or link between the current bilateral knee disorders, first noted after service, and service, there is no competent medical evidence that supports the claims. In fact, clinicians who have treated the Veteran for knee problems appear to relate onset of the bilateral knee disorders after discharge from service and associated with trauma post-service discharge. As the competent medical evidence does not show that it is at least as likely as not that the Veteran currently suffers from a right or left knee disability, to include arthritis, that was incurred service, and in the absence of competent medical evidence linking any current right or left knee disability to service, service connection must be denied. The Board recognizes the Veteran's contentions as to the diagnosis and relationship between bilateral knee arthritis, status post-total left knee replacement with revision, and service. The Board acknowledges that the Veteran is competent to give evidence about what he experienced; for example, he is competent to discuss ongoing knee pain or other observable problems. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, the currently diagnosed arthritis and its medical causation are not subject to lay observation or assertion, and fall outside the realm of common knowledge of a lay person. The diagnosis of arthritis is based on clinical findings, to include radiographic studies. For this reason, arthritis is not a simple medical condition that the Veteran is competent to etiologically relate to any medical disability or disorder as he is not shown to be qualified through education, training, or experience to interpret clinical findings of a disease process or interpret diagnostic studies and determine its etiology. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Given the complex nature of the Veteran's right and left knee disorders, his assertions do not constitute competent medical evidence that he suffers from bilateral knee disability that is a result of service. Thus, in summary, the most credible and probative evidence shows that bilateral knee arthritis manifested more than 1 year after discharge from service and is not otherwise related to service. For these reasons, the preponderance of the evidence weighs against the award of service connection for the claimed right and left knee conditions and the claims must be denied. In reaching these conclusions, the Board notes that, under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be given to the claimant in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran's claims in this case, and that doctrine is not applicable. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a psychiatric disorder, to include PTSD with depression, is granted. Service connection for right a foot skin disorder is granted. Service connection for a left foot skin disorder is granted Service connection for right ear hearing loss is denied. Service connection for a right knee disorder is denied. Service connection for a left knee disorder is denied. ____________________________________________ DEMETRIOS G. ORFANOUDIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs