Citation Nr: 1316016 Decision Date: 05/15/13 Archive Date: 05/29/13 DOCKET NO. 10-46 320 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for ganglion cyst of the left knee. 2. Entitlement to an initial evaluation in excess of 10 percent prior to June 3, 2009, for low back strain. 3. Entitlement to service connection for gout of the left great toe. 4. Entitlement to service connection for bilateral plantar fasciitis. 5. Entitlement to service connection for deep vein thrombosis of the right lower extremity. 6. Entitlement to service connection for bruxism. 7. Entitlement to service connection for bronchitis. 8. Entitlement to service connection for ear infection. 9. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD). 10. Entitlement to service connection for erectile dysfunction. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. P. Simpson, Counsel INTRODUCTION The Veteran served on active duty from December 1980 to April 1981 and from March 2005 to May 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2009 and August 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. In March 2013, the Veteran presented personal testimony before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Board has reviewed the Veteran's claims file and the record maintained in the Virtual VA paperless claims processing system. The issues of entitlement to service connection for a psychiatric disorder, to include PTSD, and entitlement to erectile dysfunction are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Ganglion cyst of the left knee is manifested by limitation of flexion to 110 degrees with pain beginning at 60 degrees. 2. Prior to June 3, 2009, the preponderance of the evidence is against a finding that low back strain was manifested by forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 3. The Veteran was diagnosed with gout in the left great toe in service and diagnosed with gout following service discharge; the two diagnoses cannot be disassociated from each other. 4. The Veteran was diagnosed with bilateral plantar fasciitis in service and diagnosed with bilateral plantar fasciitis following service discharge; the two diagnoses cannot be disassociated from each other. 5. The Veteran was diagnosed with deep vein thrombosis in the right leg and continues to take Coumadin for the diagnosis. 6. There is no competent evidence of a nexus between the diagnosis of bruxism and service. 7. There is no competent evidence of bronchitis that had its onset in service. 8. There is no competent evidence of an ear infection that had its onset in service. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 10 percent for ganglion cyst of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2012). 2. The criteria for an initial evaluation in excess of 10 percent prior to June 3, 2009, for low back strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5237 (2012). 3. Gout in the left great toe was incurred in service. 38 U.S.C.A. § 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 4. Bilateral plantar fasciitis was incurred in service. 38 U.S.C.A. § 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 5. Deep vein thrombosis in the right lower extremity was incurred in service. 38 U.S.C.A. § 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 6. Bruxism was not incurred in or aggravated by service. 38 U.S.C.A. § 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 7. Bronchitis was not incurred in or aggravated by service. 38 U.S.C.A. § 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 8. Ear infection was not incurred in or aggravated by service. 38 U.S.C.A. § 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) lays out the duties to notify and assist claimants in connection with VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim. 38 U.S.C.A. § 5103(a); C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was provided with VCAA notice in a July 2008 letter. See letter. This letter informed him of the evidence necessary to substantiate a claim for service connection, what evidence VA would obtain, what evidence he was expected to provide, and of what assistance VA could provide in obtaining evidence. This letter also informed him of how disability evaluations and effective dates are assigned. Because the claims for service connection for a left knee disability and a low back disability were granted, there is no issue regarding whether the duty to notify has been met. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate the claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(d). VA will help a claimant obtain records relevant to his claim(s), whether or not the records are in Federal custody, and that VA will provide a medical examination and/or opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has met the duty to assist the Veteran in the development of the claims. The Veteran's service treatment records have been obtained from the Veteran's second period of service. The Veteran had a period of service from 1980 to 1981. VA attempted to obtain these records and was unsuccessful in obtaining the records. VA properly completed a memorandum laying out the steps it took to obtain the records and determining that it had exhausted its efforts and that further attempts to obtain the records would be futile. VA then informed the Veteran of its inability to obtain the records and offered him an opportunity to submit the records. The Veteran responded that he had no service treatment records. VA obtained private medical records from St. Joseph's Hospital. VA also provided the Veteran with VA examinations in connection with all the issues. The Board is aware that the only (and most recent) VA examination for the left knee was in 2008. The Board does not find that a remand is warranted for a more recent VA examination. During the appeal, the Veteran's complaints in the treatment records do not involve his knee-they involve complaints associated with his feet due to plantar fasciitis and gout. When the Veteran has had VA medical professionals write letters for him to his work involving pain the Veteran is experiencing, the complaints involve his feet and not his left knee. See August 2009 letter, October 2009 letter, April 2010 document, May 2010 letter, July 2010 letter, and March 2012 letter. Additionally, the Veteran has made no statement either in writing or at the March 2013 hearing that his left knee has worsened during the appeal period. Rather, the Veteran's only allegation has been that his left knee should be rated higher. For these reasons, the Board finds that a more recent VA examination is not needed. As noted in the Introduction, VA provided the Veteran with a hearing before the Board. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the undersigned fully explained the issues involved. See transcript on page 2. While the undersigned did not suggest the submission of evidence that may have been overlooked, the Board finds there was no prejudice for two reasons. Specifically, during the hearing, the Veteran's representative asked the Veteran about each disability and why he felt that it was incurred in service. The representative also asked the Veteran why he felt he warranted higher ratings for the left knee and low back disabilities. Additionally, in the statement of the case and the supplemental statements of the case, the RO informed the Veteran of why service connection was not being granted for bruxism, bronchitis and ear infection and why increased ratings were not being granted for the left knee and the low back. Such conclusions by the RO put the Veteran on notice of what these claims were lacking. Therefore, to the extent that the Board did not meet all the requirements described in 38 C.F.R. § 3.103(c)(2) and Bryant, there has been no prejudice. The Board notes that it is remanding the claim for service connection for a psychiatric disorder to obtain additional VA treatment records. At the March 2013 hearing, the Veteran indicated he was being treated by VA for the psychiatric disorder, to include having an appointment on the day of the hearing. The Board finds it can decide the other claims because the Veteran did not indicate he was being treated for the other disabilities. For the above reasons, the Board finds the duties to notify and assist have been met, and it may consider these claims at this time. II. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). When a question arises as to which of two evaluations shall be assigned, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons used to support the conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. § 4.1 (2012), which requires that each disability be viewed in relation to its history and that there be an emphasis placed upon the limitation of activity imposed by the disabling condition, and 38 C.F.R. § 4.2 (2012), which requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. The appeal of the Veteran's claims for increase for the left knee and the low back are based on the assignment of an evaluation following an initial award of service connection. As such, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Id. The Court has held that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 (2012) and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 (2012). See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that the disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. According to this regulation, it is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 (2012). In sum, when evaluating joint disabilities rated on the basis of limitation of motion, VA may consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The Court has also held that when rating spine disabilities, the Board must discuss any additional limitation of motion that a veteran has due to pain, weakness, or fatigue. Cullen v. Shinseki, 24 Vet. App. 74, 85 (2010). A. Ganglion cyst of the left knee The service-connected ganglion cyst of the left knee is rated by analogy to limitation of flexion of the knee. The normal range of motion for the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2012). Under Diagnostic Code 5260, flexion limited to 60 degrees warrants a 0 percent rating; flexion limited to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Under Diagnostic Code 5261, extension limited to 5 degrees warrants a 0 percent rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 30 degrees warrants a 40 percent rating; and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Separate ratings may be assigned where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260 and a compensable limitation of extension under Diagnostic Code 5261, provided that the degree of disability is compensable under both sets of criteria. VAOPGCPREC 09-04 (2004); 69 Fed. Reg. 59,990 (2004). A separate rating may also be assigned for instability of the knee under Diagnostic Code 5257 where entitlement to separate compensable ratings is shown. VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997). Under Diagnostic Code 5257, a 10 percent rating is assigned for slight recurrent subluxation or lateral instability of the knee. A 20 percent rating is assigned for moderate recurrent subluxation or lateral instability. A 30 percent rating is assigned for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a (2012). After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against the award of an initial evaluation in excess of 10 percent for ganglion cyst of the left knee. At the time of the August 2008 VA examination, the Veteran's left knee had range of motion of 0 to 110 degrees with pain beginning at 60 degrees. After repetitive use, flexion was still limited to 110 degrees. Such range motion establishes no more than a 10 percent rating for limitation of flexion and establishes that a separate compensable rating for limitation of extension is not warranted. The examiner made a specific finding that there was no instability of the left knee, and thus a separate rating based upon instability is not warranted. While the examiner made a notation that the meniscus was abnormal, it appears it was based upon pain in the area. The service treatment records show that the Veteran did not sustain a meniscal tear during service. See August 2006 MRI (showing no evidence of meniscal tearing). The Veteran himself has not claimed that he sustained a meniscal tear. Additionally, the VA examiner noted that the Veteran's limitation of motion was based upon the ganglion cyst. Thus, a separate compensable rating for meniscus involvement is not warranted. The Board has also considered whether the Veteran is entitled to a referral for an extraschedular rating, which is a component of a claim for an increased rating under Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service (Director). Thun v. Peake, 22 Vet. App. 111, 115 (2008). The threshold factor is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. "[I]nitially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability." Id. The Court provided that "if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required." Id. The Board finds that the currently-assigned 10 percent rating fully contemplates the Veteran's symptoms. The Veteran has limitation of flexion as a result of the ganglion cyst, and his disability is rated based upon that limitation of flexion. The 10 percent rating contemplates flexion limited to 45 degrees. In the August 2008 VA examination report, the examiner stated the Veteran's flexion was limited to 110 degrees with pain beginning at 60 degrees. Thus, the Veteran's limitation of motion is contemplated by the criteria. Additionally, the Veteran's complaints of pain are contemplated in evaluations of the musculoskeletal system. See 38 C.F.R. §§ 4.40, 4.45. Thus, the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disability. Accordingly, the schedular evaluation is not inadequate and referral of this case for consideration of an extra-schedular rating is not warranted. Id. Accordingly, in view of the denial of entitlement to an initial evaluation in excess of 10 percent for ganglion cyst of the left knee, the Board finds no basis upon which to predicate assignment of "staged" ratings pursuant to Fenderson, supra, as the evidence does not show that a higher rating is warranted for any distinct period(s) of time. In reaching all the conclusions above, the Board has considered the applicability of the benefit-of-the-doubt doctrine. As the preponderance of the evidence is against the claim, such doctrine is not applicable. 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1991). B. Low back strain In the August 2009 rating decision on appeal, the RO granted service connection for low back strain and assigned a 10 percent rating, effective May 8, 2008, and a 40 percent rating, effective June 3, 2009. The Veteran has appealed the 10 percent evaluation. At the March 2013 hearing, the Veteran testified that he felt his back should be rated at the 40 percent rating since service connection was awarded. Low back strain is evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5237. The general rating formula evaluates diseases and injuries of the spine. These criteria are controlling regardless of whether there are symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. In this respect, a 10 percent evaluation is warranted when forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees, or the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is in order for forward flexion of the thoracolumbar spine of 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. While the Veteran's allegation is that he is entitled to a 40 percent rating prior to June 3, 2009, the Board finds that the Veteran's claim involves entitlement to an evaluation in excess of 10 percent prior to June 3, 2009. In other words, the Board finds that the Veteran is not limiting his entitlement to a higher rating prior to June 2009 solely to the 40 percent evaluation, but any evaluation that exceeds the currently-assigned 10 percent evaluation. The Veteran had been provided with a VA examination in April 2009; however, the examiner neglected to report ranges of motion, and thus a new examination was scheduled, which was completed in June 2009. It was based upon the clinical findings of limitation of motion that the RO chose to assign the June 2009 date as the effective date for the increased rating. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against an initial evaluation in excess of 10 percent prior to June 3, 2009. Prior to this date, there is a lack of clinical findings of the Veteran's specific range of motion of the lumbar spine. However, the Board finds that the preponderance of the evidence is against a finding that the Veteran's low back disability was any more than mildly disabling. For example, when examined in July 2008, the examiner noted there was tenderness without erythema or swelling in the lumbar spine. There was no ankylosis, and the Veteran had negative straight leg raising. There was pain with internal and external torso rotation. When examined in April 2009, the examiner found that the Veteran exaggerated his symptoms. For example, he wrote, "On very light superficial touch by the examiner in the lumbar area, the [V]eteran jumps forward groaning and wincing, describing intense pain, clearly out of line with testing procedure." The examiner also wrote that the Veteran had marked exaggerated painful response to light pressure at different varied local points in the lumbar spine. He concluded that the presentation of symptoms and physical examination were highly indicative of a strong nonorganic component to the Veteran's pain. The Board finds that the negative findings regarding the Veteran's credibility in accurately representing his symptoms is evidence against entitlement to a higher rating for the service-connected low back strain. In other words, because the Board cannot rely on the Veteran's representation of his symptoms, it accords his allegation of increased symptoms little to no probative value. In the June 2009 VA examination report, the examiner there also noted that the Veteran was "exquisitely tender all the way across his low back" and that "even lightly brushing his skin causes him to try to reach around and try to take my hand away from his skin." This further supports the Board's conclusion to accord little to no probative value to the Veteran's allegations that his back pain is worse than the 10 percent rating contemplates. The Board has considered whether an extraschedular rating is warranted; however, it finds that the currently-assigned 10 percent rating fully contemplates the Veteran's low back symptoms. The 10 percent rating contemplates forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of the height. In the July 2008 VA examination, the examiner described painful motion. The 10 percent rating contemplates limitation of motion due to pain, which is what the Veteran had prior to June 2009. The criteria for evaluating back disorders specifically includes pain, and thus the Veteran's complaints of pain are contemplated in the 10 percent rating. The RO has staged the Veteran's rating. In view of the denial of entitlement to an initial evaluation in excess of 10 percent for low back strain prior to June 2009, the Board finds no basis upon which to predicate assignment of "staged" ratings pursuant to Fenderson, supra, during the period prior to June 2009, as the evidence does not show that a higher rating is warranted for any distinct period(s) of time. In reaching all the conclusions above, the Board has considered the applicability of the benefit-of-the-doubt doctrine. As the preponderance of the evidence is against the claim, such doctrine is not applicable. 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1991). III. Service Connection The Veteran alleges that service connection for bruxism, gout, plantar fasciitis, deep vein thrombosis, bronchitis and ear infection is warranted. Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). For certain chronic diseases, such as arthritis (degenerative joint disease), service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). In order to prevail on the issue of service connection, there must be competent evidence of (1) a current disability; (2) 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 disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). A. Gout After having carefully reviewed the evidence of record, the Board finds that the evidence supports the award of gout in the left great toe. The service treatment records show that the Veteran was diagnosed with gout in the left great toe. The post service treatment records show that the Veteran was diagnosed with gout in the left great toe. While the July 2008 VA examination report shows that the Veteran was not experiencing gout at that time, the Board finds that it cannot disassociate the in-service diagnosis with the post-service diagnosis. In an October 2009 letter, wherein the VA examiner wrote that the Veteran had a history of gout from which he would experience episodic flare-ups, which is indicative of the Veteran having gout following service discharge. The Board concludes that what he had in service is what he has following service discharge. Accordingly, the claim for service connection for gout of the left great toe is granted. B. Plantar fasciitis After having carefully reviewed the evidence of record, the Board finds that the evidence supports the award of service connection for bilateral plantar fasciitis. The service treatment records show that the Veteran was diagnosed with bilateral plantar fasciitis. The post service treatment records show that the Veteran was diagnosed with bilateral plantar fasciitis. While the July 2008 VA examination report shows that bilateral plantar fasciitis was resolved, the Board finds that it cannot disassociate the in-service diagnosis with the post-service diagnosis. Based on an October 2009 letter, wherein the VA examiner wrote that the Veteran had a history of plantar fasciitis, he noted that the Veteran continued to have bilateral plantar fasciitis, the Board concludes that what he had in service is what he has following service discharge. Accordingly, the claim for service connection for bilateral plantar fasciitis is granted. C. Deep vein thrombosis After having carefully reviewed the evidence of record, the Board finds that the evidence supports the award of service connection for deep vein thrombosis of the right lower extremity. The service treatment records show that the Veteran was diagnosed with deep vein thrombosis of the right lower extremity. In the July 2008 VA examination report, the examiner noted that there was no evidence of deep vein thrombosis; however, there was a notation in the report that the Veteran was still taking Coumadin for the disability. The purpose of taking the Coumadin is to avoid the deep vein thrombosis. Just because the Veteran does not have deep vein thrombosis at the time of examination does not mean that the disability does not exist. The Board will resolve all reasonable doubt in favor of the Veteran. Accordingly, the claim for service connection for deep vein thrombosis of the right lower extremity is granted. D. Bruxism After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against the award of service connection for bruxism. The Veteran claims he developed bruxism in service during his second period of service. See VA Form 21-526, Veteran's Application for Compensation or Pension, received in July 2008. Of record are multiple service treatment records from the Veteran's second period of service. There are multiple complaints documented in the service treatment records; however, there is no documentation of the Veteran complaining of bruxism or grinding of his teeth during service, including the Report of Medical History completed by the Veteran in December 2007. In fact, when asked about whether he had severe tooth or gum trouble, the Veteran specifically denied any such history. Additionally, the service dental treatment records do not show complaints by the Veteran of grinding his teeth or complaints that would indicate grinding his teeth, such as headaches or waking up with jaw pain. When he completed a Dental Patient Medical History in January 2008, at no time did he report issues involving grinding his teeth. The Board finds as fact that had the Veteran been having issues with grinding his teeth during service, it would have been documented in the service treatment records, such as the dental treatment records, the January 2008 dental history document, or the December 2007 Report of Medical History. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (Lance J., concurring) (discussing the distinction between cases in which there is a complete absence of any evidence to corroborate or contradict lay testimony, as opposed to cases in which there is evidence that is relevant either because it speaks directly to the issue or allows a reasonable inference to be drawn by the Board as factfinder). When the Veteran was examined in July 2008, the examiner concluded that the disability may or may not be attributable to the Veteran's service. This opinion is speculative and does not provide a nexus to service. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); Tirpak v. Derwinski, 2 Vet. app. 609, 611 (1992) (medical evidence which merely indicates that the alleged disorder "may or may not" exist or be related to service, is too speculative to establish the presence of the claimed disorder or any such relationship). The Board does not find that a clarification opinion is needed, as the nexus evidence must be based upon the Veteran's allegation that he began grinding his teeth in service. The Board finds that the Veteran's post service allegation of grinding his teeth during service to lack credibility. Again, the service treatment records from the Veteran's second period of service show multiple complaints of pain in various locations, but not complaints associated with grinding his teeth. His dental treatment records are silent for complaints pertaining to grinding his teeth. He did not report such in the January 2008 dental medical history or in the report of medical history. The Board finds that had the Veteran been experiencing grinding of his teeth during service, it would have been documented in the service treatment records, including through his own report of medical history. Without credible evidence of a nexus to service, service connection for bruxism is denied. In reaching the conclusion above, the Board has considered the applicability of the benefit-of-the-doubt doctrine. As the preponderance of the evidence is against the claim, such doctrine is not applicable. 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102. E. Bronchitis At the March 2013 hearing, the Veteran testified they did night training. He reported that they were gassed and that he tried to get his protective mask on, but that in the meantime it had gotten into his mouth. The implication was that this was the start of the Veteran's respiratory disorder. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against the grant of service connection for bronchitis. The service treatment records do not show any treatment for bronchitis. The Veteran reported a history of bronchitis in the Report of Medical History he completed in December 2007. However, in reading through the post service treatment records, there is no showing of bronchitis or symptoms of bronchitis in the years following service discharge. While the Veteran is competent to report having respiratory symptoms, however, there is a lack of medical evidence to substantiate chronic or continuous symptoms. When the Veteran was examined in July 2008, he was asked by the examiner about his nose, which symptoms were reported as "None." When asked about the mouth and throat, the examiner wrote only that the Veteran complained of teeth grinding. There had been no episodes of sinusitis in the last 12 months. The Veteran's original claim for service connection, submitted in July 2008, did not include a claim for service connection for bronchitis, which tends to establish that the Veteran did not believe he had incurred bronchitis in service . Again, the post service treatment records do not show treatment for bronchitis, and the Veteran has not provided statements or testimony regarding the symptoms and/or diagnosis of a respiratory disorder. Accordingly, the Board finds the preponderance of the evidence is against a finding that the Veteran has bronchitis. In other words, the Board finds the preponderance of the evidence is against a finding of a current disability. In reaching the conclusion above, the Board has considered the applicability of the benefit-of-the-doubt doctrine. As the preponderance of the evidence is against the claim, such doctrine is not applicable. 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102. F. Ear infection After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against the grant of service connection for ear infection. When the Veteran submitted his informal claim for service connection, he reported he had an ear infection in service and believed he was experiencing residuals. At the March 2013 hearing, the Veteran did not provide testimony on what symptoms he currently had or why he believed he still had residuals. The service treatment records do not show treatment for an ear infection. In the December 2007 Report of Medical History, the Veteran specifically denied any ear, nose or throat trouble. When he was examined in July 2008, the examiner examined both ears and found no symptoms. The post service treatment records do not show treatment for or a diagnosis of an ear infection. Thus, both the Veteran's lay statements and the medical records fail to establish a post service disability. In other words, even if the Board conceded that the Veteran had an ear infection in service, there is no evidence, either lay or medical, of an ear infection following service discharge. The Board finds the preponderance of the evidence is against a finding of a current disability. In reaching the conclusion above, the Board has considered the applicability of the benefit-of-the-doubt doctrine. As the preponderance of the evidence is against the claim, such doctrine is not applicable. 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to an initial evaluation in excess of 10 percent for ganglion cyst of the left knee is denied. Entitlement to an initial evaluation in excess of 10 percent prior to June 3, 2009, for low back strain is denied. Entitlement to service connection for gout of the left great toe is granted. Entitlement to service connection for bilateral plantar fasciitis is granted. Entitlement to service connection for deep vein thrombosis in the right lower extremity is granted. Entitlement to service connection for bruxism is denied. Entitlement to service connection for bronchitis is denied. Entitlement to service connection for ear infection is denied. REMAND As to the claims for entitlement to service connection for a psychiatric disorder, to include PTSD, and service connection for erectile dysfunction, the Board finds additional development is warranted before the Board can decide these two remaining issues. At the March 2013 hearing, the Veteran testified he was receiving treatment for psychiatric symptoms at the VA in Jamaica Plain, Massachusetts, to include having an appointment on the same day he had the Board hearing. See transcript on pages 7-8. There are no VA treatment records in the file from this facility pertaining to treatment for psychiatric symptoms. Thus, these records must be secured, as they are relevant to the issue for service connection for a psychiatric disorder. The Veteran claims that he was told that erectile dysfunction was due to his left knee and low back. The Board finds that a VA examination and medical opinion are warranted in connection with this claim. Accordingly, the case is REMANDED for the following action: 1. Obtain the VA treatment records from the VA Medical Center in Boston, Massachusetts, which should include any treatment at the Jamaica Plains facility from May 2008 to the present time. 2. Schedule the Veteran to undergo a genitourinary examination by an appropriate professional. All appropriate tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner is asked to answer the following questions: (i) Is it at least as likely as not that the Veteran developed erectile dysfunction during service? (ii) If the answer to (i) is no, is it at least as likely as not that the Veteran's erectile dysfunction is proximately due to, or permanently aggravated at least in part by, his service-connected lumbar spine disability and/or by his service-connected left knee disability. The examiner should set forth a complete rationale for the conclusions reached. 3. Thereafter, undertake any other development action that is deemed warranted, and re-adjudicate the claims on the merits. If any of the benefits sought is not granted, the Veteran and his representative should be furnished a supplemental statement of the case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs