Citation Nr: 1318041 Decision Date: 06/03/13 Archive Date: 06/11/13 DOCKET NO. 08-26 414 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a left leg disability, other than gout, feet, and ankle disabilities. 2. Entitlement to service connection for a right leg disability, other than feet, gout, and ankle disabilities. 3. Entitlement to service connection for a skin disability. ATTORNEY FOR THE BOARD Russell P. Veldenz, Counsel INTRODUCTION The Veteran served on active duty from August 1990 to August 1994. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In the April 2007 rating decision, the RO also denied a claim for service connection for irritable bowel syndrome and the Veteran included that denial in his notice of disagreement. In a rating decision dated in March 2012, the RO granted service connection for irritable bowel syndrome. This is a full grant of benefits sought on the issue of service connection for irritable bowel syndrome and it is therefore no longer before the Board. In July 2012 and February 2013, the Board remanded the case to the RO to provide the Veteran a VA examination and to obtain medical opinions as to what manifestations of the legs and/or skin rash were caused by the Veteran's service and their level of severity. VA has afforded the Veteran VA examinations and the examiners have issued reports and addendums. In the reports and addendums, the examiners sufficiently identified the extent of the disability and its symptoms and whether each disability is related to service. After review of the reports and addendums, the Board finds the VA examination reports and addendums in compliance with 38 C.F.R. § 3.159(c) (4), that is, sufficient competent medical evidence to make a fully informed decision on the claim. As the requested development has been completed, no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. The Veteran was not diagnosed or treated for left leg disability, including osteoarthritis of the left knee, or symptoms of a left leg disability in service and a left leg disability was not manifested to a compensable degree within one year from the date of separation from service; and is unrelated to an injury or disease or event in service. 2. The Veteran was not diagnosed or treated for right leg disability, including osteoarthritis of the right knee, or symptoms of a right leg disability in service and a right leg disability was not manifested to a compensable degree within one year from the date of separation from service; and is unrelated to an injury or disease or event in service. 3. Resolving the benefit of the doubt in favor of the Veteran, the Veteran's current skin disabilities, seborrheic dermatitis and a nonspecific dermatitis, had their onset in active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a left leg disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. The criteria for service connection for a right leg disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 3. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for a skin disability, diagnosed as seborrheic dermatitis and a nonspecific dermatitis, have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 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 v. Nicholson, 19 Vet. App. 473, 484-86 (2006). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The RO provided pre- adjudication VCAA notice by letter, dated in June 2006. The notice included the type of evidence needed to substantiate the underlying claims of service connection, namely, evidence of an injury or disease or event, causing an injury or disease, during service; evidence of current disability; and evidence of a relationship between the current disability and the injury or disease or event, causing an injury or disease, during service. The Veteran was notified that VA would obtain service treatment records, VA records, and records from other Federal agencies, and that he could submit other records not in the custody of a Federal agency, such as private medical records or with his authorization VA would obtain any non-Federal records on his behalf. The notice included the provisions for the effective date of a claim and for the degree of disability assignable. As for content of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (38 C.F.R. § 3.159 notice); and of Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The RO has obtained service treatment records, VA records, records from private medical caregivers, and afforded the Veteran VA examinations in July 2006 and September 2012. The reports of the VA examination in September 2012 with addendums in April 2013included a review of the Veteran's medical history, including his service treatment records, an interview and an examination of the Veteran, sufficient findings to rate any disability and offered opinions whether any current disability is related to service. Therefore, the Board concludes that the VA examinations are adequate. 38 C.F.R. § 4.2; see Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The Board notes that there is some documentation in the file indicating the Veteran was in the reserves after active duty. Veteran advised VA in July 2012 that he was in the reserves for only a short period of time and VA has not been able to locate any other records, whether pertaining to treatment, or the Veteran's dates of reserve component service, including all dates of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) from the appropriate sources including the Records Management Center. Therefore, the Board finds VA has fulfilled the duty to assist as it relates to obtaining records from the reserves. 38 C.F.R. § 3.159 (C) (2). As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. Facts and Analysis Service connection may be granted for 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. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may be established by continuity of symptomatology after service under 38 C.F.R. § 3.303(b). The Federal Circuit recently held, however, that continuity of symptomatology under 3.303(b) applies only to chronic diseases listed in § 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (2013). There is evidence in the file that the Veteran suffers from degenerative disease of the knees. Degenerative disease is listed as arthritis as a disease under § 3.309 as a chronic disease, and therefore the provisions of § 3.303(b) do apply as to those claims. The Veteran's skin rash disability, variously diagnosed as miliariasis, an allergic reaction to medication, seborrheic dermatitis, and a nonspecific dermatitis, is not listed as a disease under § 3.309 as a chronic disease, and the provisions of § 3.303(b) do apply as to that claim. The showing of a chronic disease in service requires a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for certain disabilities such as arthritis (degenerative disease) or organic diseases of the nervous system, if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). VA must give due consideration to all pertinent lay and medical evidence in a case where a Veteran is seeking service connection. 38 U.S.C.A. § 1154(a). Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and weight, factual determinations going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competency is a question of fact, which is to be addressed by the Board. Jandreau, v. Nicholson, 492 F.3d 1372, 1377 (2007). When the evidence is admissible, the Board must then determine whether the evidence is credible. "Credible evidence" is that which is plausible or capable of being believed. See Caluza v. Brown, 7 Vet. App. 478, 51 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (the determination of credibility is a finding of fact to be made by the Board in the first instance). If the evidence is credible, the Board, as fact finder, must determine the probative value or weight of the admissible evidence, that is, does the evidence tend to prove a material fact. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). If the evidence is not credible, the evidence has no probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Service Connection for Right and Left Leg Disabilities The Veteran seeks service connection for disabilities of the legs. The Veteran has gout but entitlement to service connection was denied by the Board in February 2013. Therefore, to the extent the Veteran's lower legs are affected by gout, it is not analyzed in this decision. Gout is discussed in the context of discussing the Board's review of the medical evidence. The February 2013 Board decision denied entitlement to service connection for disabilities of the right and left foot, including the ankles. Again, the Board discusses the feet, including the ankles, only in the context of the medical evidence. The Veteran, however, is service connected for a lumbar strain disability since June 2005. It is currently rated at 40 percent. Therefore, the Board will discuss whether any current disabilities of the legs are symptoms of his service-connected back disability. The entrance examination in June 1990 did not include a history of any joint pain, swelling, or other symptoms relating to the lower extremities. The physical examination of the joints was normal. In June 1994, the Veteran complained of constant pain and tightness in his right thigh after playing soccer. The diagnosis was a strained muscle. In July 1994, in the separation examination, the Veteran reported a history of cramps in the leg and foot trouble. The examiner noted that the Veteran made reference to one episode of thigh cramping the previous winter. It is unclear if the Veteran was referring to the thigh pain that caused him to seek treatment. The Veteran also had what appears to be occasional tinea pedis (athlete's foot), although the notation is partially illegible. The physical examination for both the feet and the lower extremities was normal. In a document dated in August 1996 that was marked as treatment while a reservist, the Veteran reported right toe pain in the plantars aspect that hurt when he walked on it. He denied any recent history of injury or history of gout. He walked with a limp and the toe was slightly swollen and warm to the touch, with tenderness near the joint area. No diagnosis was recorded. The Board notes the Veteran advised VA in July 2012 that he was in the reserves for only a short period of time, about a month, and VA has not been able to locate any other records, whether pertaining to treatment, or the Veteran's dates of reserve component service, including all dates of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). As there is no evidence to the contrary, the Board finds that the treatment in August 1996 did not occur while the Veteran was on active duty as a reservist. After service, the Veteran submitted medical records from the Guajira Family Clinic and Dr. Alfredo Gonzalez which reveals that the Veteran was diagnosed and treated for gout as it manifested in the toes and ankles. A report of X-rays of the left and right ankles dated in January 2002 stated the right ankle showed an incompletely united fracture of the distal tibia. There were slight degenerative changes in the right talotibial joint. Incidentally shown were minimal degenerative changes in the right talonavicular joint. The left ankle did not show any significant degenerative changes. In a VA examination in July 2006, the Veteran complained of bilateral foot pain, muscle pain of the lower extremities, and back pain. The foot pain manifested itself as chronic pain in his tendons since the 1990s. The lower extremity pain has existed since 1999 affecting all muscles of the legs and feet bilaterally and described as a migrating condition from joint to joint. The examiner noted the Veteran complained of severe pain throughout the examination and could not do many movements due to pain, including difficulty getting onto the examination table. In particular, the left knee showed edema, swelling, and effusion with decreased motion. The left ankle showed swelling but had a full range of motion. The examiner also noted the Veteran limped when walking. X-rays from the examination showed a posterior thickening in the mid right fibula, thickening in the left mid tibial cortex, and talar spurring in the left foot. An X-ray of the right foot presented what the examiner believed to represent an atypical appearance of gout. As to the complaints of bilateral foot pain and lower extremity muscle pain, the diagnosis was gout. The examiner noted the Veteran has pain that migrates between different joints and different tendons consistent with gout. The examiner noted his findings regarding the left knee and ankle (pain, swelling, and effusion) related to the diagnosis of gout. VAMC treatment records start in July 2007, where the Veteran was already noted to suffer from gout and by August 2008, it also began to affect his upper extremities such as his left elbow. The Veteran at his first VAMC visit stated the knee pain had existed for 10 years, but he later stated he had suffered bilateral foot and knee pain since he left military service. He also gave a history of a right ankle fracture treated with a cast. The notes do not indicate when the ankle fracture occurred. In May 2011, X-rays demonstrated mild degenerative changes in the left lateral compartment. In September 2012, the Veteran underwent a VA examination. The Veteran reported problems with his feet and toes in service necessitating treatment on 4 to 5 occasions, but the examiner noted no such treatment in the service treatment records. The Veteran also attributed his knee problems to falling and hitting his knees while walking up a hill. It is not clear from the report if this happened during service, or afterwards, but the examiner observed that a specific injury to the knees, any time either in service or after, was not noted at in his medical records. It appears, however, the Veteran was reporting an in-service event. Minimal osteoarthritis of both knees was also diagnosed in the X-rays. Specifically, bilateral tibia spine spurring and medial compartment joint space narrowing was noted. The VA examiner concluded that the Veteran did not have a diagnosis or symptoms of a muscle injury, peripheral nerve condition, or peripheral neuropathy. The examiner did not find any objective signs of radiculopathy and observed that objective evidence of radicular symptoms was not noted in the records. The examiner specifically noted that during sensory testing, the Veteran was asked to close his eyes and relate whether he felt the monofilament. The Veteran said yes except for the L5 and S1 distribution of both feet where he answered no. If there was no sensation in these areas, he would not have felt any pressure and would not have answered no. Therefore the examiner stated it represented pain behavior and was consistent with other portions of the examination. The examiner therefore concluded the Veteran had age-related degenerative changes of the spine which does not cause or aggravate radicular symptoms. The examiner made three diagnoses. First, the Veteran had a prior fracture of the right ankle, which resulted in a nonunion of the medial malleous, a healed fracture of the middle portion of the fibula, and early arthritic changes in the right ankle. The examiner noted, however, that by the Veteran's own history, the fracture occurred in 2000, that is, after service. The ankle fracture also explained findings of periosteal thickening in the mid fibula, and thickening in the left mid tibial cortex in July 2006 X-rays. Second, the Veteran had gouty arthritis of both great toes, which was worse in the right great toe. The cystic changes and other findings of the feet noted are secondary to the gouty arthritic changes. Finally, there is a fragmentation of the posterior process of the left talus, which is a normal variant. The VA examiner also considered that the Veteran is service connected for lumbar strain and examined the back as well. Examination was normal and there a normal range of motion. There were, as noted, no signs or symptoms of peripheral neuropathy that resulted in radiculopathy as a result of the back disability. The examiner specifically stated that the single notation of leg cramps in service is unrelated to any of the conditions diagnosed. In November 2012, the X-ray of the knees demonstrated mild degenerative changes of the left femorotibial compartment and a negative limited examination of the right knee. In March 2013, the Veterans' left knee was X-rayed after a clinical history of left knee pain after twisting the left leg while walking and effusion was noted. The X-ray revealed normal bone density without fractures or dislocations. Tricompartmental joint space narrowing with marginal osteophytosis was present as was a small knee joint effusion. Tibia spine spurring was also noted. The diagnosis was small left knee effusion and mild tricompartmental osteoarthritis. In an addendum dated in April 2013, the examiner discussed the relationship of the bilateral knee osteoarthritis to service including the fall described by the Veteran. The examiner noted that the Veteran related his knee problems to falling and hitting his knees while walking up hills in service. The Veteran recalls bumping the tibial tubercle when he fell. The examiner noted, however, that he did not relate a specific injury and none were noted in the medical records. The left knee is worse than the right, but there is no sign of Osgood-Schlatter's disease The examiner noted the Veteran was on active duty from the age of 19 to 23 and now, roughly 20 years later, the Veteran has very minimal arthritic changes with the left knee worse than the right. The Veteran also has gout. The examiner has concluded age-related changes, and perhaps gouty arthritis, are much more likely the causes of the current arthritis than the injuries he described in service. There is no record of treatment until July 2007 when he described bilateral knee pain for 10 years. Using the patient's history, it was 13 years after service that demonstrate continued pain and no complaints or treatments in the medical records for 23 years after service. The examiner therefore did not find any relationship between the osteoarthritis and his history of trauma. No traumatic changes are noted in either knee and as the injury was described to the tibia tubercle area, no tenderness or fragmentation of the patellar tendon insertion was noted and no injury to the knees was documented during service. After reviewing the foregoing evidence, the Board has concluded that the Veteran does not have an orthopedic or neurological disability (such as radiculopathy form his lumbar strain disability) related to the knees connected to service. The Board recognizes that the Veteran believes he has a condition that has caused him pain in his lower extremities since separation. The Veteran is competent to testify to the events in service and after, including when he developed pain. 38 C.F.R. § 3.159. The question is whether the Veteran currently has a leg disability due to service. Service connection may be established by either continuity of symptomatology after service under 38 C.F.R. § 3.303(b) or by initial diagnosis of the medical condition after service under 38 C.F.R. § 3.303(d). The Board notes the Veteran has testified that he first experienced joint pain which continued after service. As a lay person, the Veteran is competent to describe pain in a joint, which he is able to perceive through the use of his senses. 38 C.F.R. § 3.159 (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge, personal knowledge is that which comes to the witness through the use of the senses). Further, the Veteran's statements and testimony are admissible and are to be considered as evidence of continuity. Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept in determining whether lay evidence may be considered, in other words, whether the evidence is admissible). The Board thus finds that the Veteran is competent to describe pain and other symptoms related to his joints such as his knees and the statements and testimony is credible. While there is evidence of continuity of symptomatology, it does not necessarily follow that there is a relationship between a current diagnosis, for example, arthritis, and the continuity of symptomatology as stated by the Veteran. Medical evidence is required to demonstrate such a diagnosis and a relationship to service unless such the diagnosis and the relationship to service is one to which a lay person's observation is competent. See Savage v. Gober, 10 Vet. App. 488, 497 (1997) (medical evidence is required to demonstrate continuity of symptomatology and any present disability unless such a relationship is one to which a lay person's observation is competent). Although the Veteran is competent to describe pain, a disability such as arthritis is not a condition under case law that has been found to be capable of lay observation, and the determination as to the presence or diagnosis of such a disability therefore is medical in nature and competent medical evidence is required to substantiate the claim. Savage, 10 Vet. App. at 498 (On the question of whether there is a chronic condition since service, the evidence must be medical unless it relates to a condition as to which, under case law , lay observation is competent); Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Arthritis, neurological disorders if present, or even gout are conditions under case law that have not been found to be capable of lay observation. See Jandreau, 492 F.3d at 1377 (explaining in a footnote, sometimes a layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); see also Barr, 21 Vet. App at 309 (varicose veins were subject to non-expert diagnosis due to the readily observable defining characteristics of the condition). Furthermore, the diagnosis of arthritis, neurological disorders (such as radiculopathy from the lumbar spine), or gout cannot be made by the Veteran as a lay person based on mere personal observation, that is, perceived by visual observation or by any other of the senses. As demonstrated by this case, the diagnosis depends upon interpretation of symptoms, and clinical and diagnostic tests, such as X-rays and laboratory tests, which requires medical knowledge. No factual foundation has been established that the Veteran is otherwise qualified through specialized education, training, or experience to offer a medical diagnosis. Therefore, the Veteran's assertion or opinion that he has an arthritis disability or a neurological disability is not competent evidence. To this extent his statements and testimony are not admissible as evidence of the presence or diagnosis of a multiple joint (bilateral knees or lower leg) disability since service based on continuity or as an opinion based on causation. The Veteran, as a lay person, is competent not only to identify a simple medical condition, but also a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As for the Veteran relating symptoms that later support a diagnosis by a medical professional, no treating physician since separation has reached a diagnosis of osteoarthritis, or a neurological disorder such as peripheral neuropathy that is caused by or otherwise related to service. Turning to the competent medical evidence before the Board, there has not been any diagnosis of a neurological disorder such as peripheral neuropathy or radiculopathy. In addition, the medical evidence does not demonstrate any disability of the legs that is part of the Veteran's service-connected back disability. Instead, as noted, the Veteran's gout is not related to service as discussed further in the February 2013 Board decision. Further, the medical evidence has attributed his joint pain over the years to the gout, before the diagnosis of osteoarthritis was made. Inasmuch as osteoarthritis was not diagnosed to a compensable degree within a year after separation, the presumption of 38 C.F.R. § 3.309 does not apply. Finally, the VA examiner, as noted, after reviewing all of the medical evidence, concluded that the Veteran's current mild osteoarthritis is related to age, not trauma, including the in-service incidents described by the Veteran where he fell while walking uphill. The expert noted the diagnostic radiologic studies do not indicate trauma and there is no documentation in the service treatment records to support an in service occurrence of the osteoarthritis. Further, based on the Veteran's own history, symptoms such as pain started well after service. The Board is not stating that the Veteran's testimony must be corroborated by contemporaneous medical records, see Buchanan v. Nicholson, 451 F. 3d 1331, 1335 (Fed. Cir. 2006) (lack of records does not, in and of itself, render lay testimony not credible). Instead, the evidence of continuity fails not because of the lack of medical documentation; rather the assertions of continuity are less probative than the negative evidence, which interrupts continuity. Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006); see also Harvey v. Brown, 6 Vet. App. 390, 394 1994) (Board decision properly assigned more probative value to a private hospital record that included lay history that was made for treatment purposes than to subsequent statements made for compensation purposes). The service treatment records and subsequent treatment records are probatively significant and given a lot of weight and credibility because they were prepared at a time contemporaneous to the alleged incident in question. See, e.g., Struck v. Brown, 9 Vet. App. 145, 155-56 (1996). As noted, the VA examiner took into account the Veteran's lay reports of symptoms and their onset to form his opinions. In light of the foregoing, the Board finds that the opinions of the VA examiner in 2012 as persuasive evidence against the claim. As the VA examiner applied medical analysis to the significant facts of the case to reach the conclusion expressed in his opinions, the Board finds the evidence competent and credible and highly probative on the material issues of fact, pertaining to the diagnosis and cause of a current disability of the right and left legs, including osteoarthritis of the knees, which opposes, rather than supports, the claims. Accordingly, the weight of the medical evidence is against an association or link between any current disabilities of osteoarthritis of the right and left knees and service, including the falls. The preponderance of the evidence is against the claim of service connection on the applicable theories of service connection, and the benefit of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Service Connection for a Rash The entrance examination in June 1990 did not report a history of any skin condition, including a rash. The physical examination was also normal. In June 1993, the Veteran complained of a rash that was present for a week before he sought treatment. The diagnosis was miliariasis. In the July 1994 separation examination, there is no notation of a skin symptom or diagnosis in the history or physical examination. In May 2006, Dr. Gonzalez noted a rash on the body and thought the Veteran was having an allergic reaction to medication. In a VA examination in July 2006, the Veteran reported skin eruptions since 1994, complaining of itching and redness for 12 years. Although the report is not clear, it appears to occur on the side of his face and he used topical medication. It flares up about once every three months. Examination did reveal an erythematous lesion 4 cm x 6 cm right below the lower lip and another similar lesion on the right lower extremity. The diagnosis was a drug eruption at least as likely as not secondary to a gout medication. In a VA examination in September 2012, the Veteran stated for many years he has had a rash along his eyebrows in the middle of his forehead. It comes and goes and manifests as red, scaley patches. He also has had a patch of red skin above his right knee in the inner aspect of his right leg. It has remained stable and not symptomatic. Both covered less than 5 percent of his exposed area and total body. The diagnosis for the facial skin condition was seborrheic dermatitis and a nonspecific dermatitis on the medial aspect of the right thigh. Neither had a known cause or etiology. The rash in service was miliariasis and is a condition caused by obstruction and inflammation of sweat glands. It is associated with living in hot, humid conditions and not related to other forms of dermatitis. Therefore, the Veteran's current forms of dermatitis are unrelated to the miliariasis documented in service. His skin conditions are also unrelated to any of his service connected disabilities (low back strain and irritable bowel syndrome) or their treatment. The examiner concluded in-service treatment for a skin condition was unrelated to any current skin lesions on the Veteran and these lesions had a known cause or etiology. The examiner stated an opinion whether they are otherwise related to service could only be made by resorting to speculation. In an addendum dated in April 2013, the examiner clarified that both forms of dermatitis were chronic, but their onset is not documented in the service treatment records and their etiology is unknown based upon current medical knowledge, citing medical literature. Therefore, he could not determine whether either form is related to service without resorting to speculation. Stated another way, the examiner could not reach an opinion as to whether the present skin disabilities are causally or etiologically related to service because the limits of medical knowledge have been exhausted. The Board recognizes that the Veteran currently has skin disabilities of the face and thigh and believes he has a skin disability related to service, specifically, the miliariasis treated in June 1993. For the same reasons the Veteran could not offer an opinion as to the relationship between his osteoarthritis of the knees and service also applies to his opinion that his current dermatitis disabilities are related to the miliariasis. Instead, the VA examiner in 2012 and 2013 concluded that the skin diagnosis in service, miliariasis, is caused by obstruction and inflammation of sweat glands and the current forms of dermatitis are unrelated to the miliariasis documented in service. He also determined there was no evidence of a relationship between the Veteran's current service-connected disabilities, their treatment such as medication, and the seborrheic dermatitis and a nonspecific dermatitis. The Veteran, however, stated that he has had a skin disability since service, even if it was not miliarias. The Veteran is competent to describe symptoms and their onset which he is able to perceive through the use of his senses. 38 C.F.R. § 3.159 (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge, personal knowledge is that which comes to the witness through the use of the senses). A Veteran's lay statements may be sufficient evidence in any claim for service connection. 38 C.F.R. § 3.303(a) ("Each disabling condition shown by a veteran's service records, or for which he seeks a service connection[,] must be considered on the basis of ... all pertinent medical and lay evidence."(emphasis added)); see 38 U.S.C. § 1154(a) (requiring VA to include in its service connection regulations that due consideration be given to "all pertinent medical and lay evidence"). The Board recognizes against his testimony is the attribution of the skin disability by his treating private physician and the VA examiner in 2006 to his gout medication. Neither physician, however, has taken into account that the skin disability started in service and has occurred intermittently since. There also was no skin symptoms note in the separation examination in 1994, but since the disability occurs intermittently, it may be that the examination occurred when symptoms were not present. Finally, the VA examiner in 2012 and 2013 could not determine without resorting to speculation if there was a relationship between service generally (and excluding the miliariasis), and the seborrheic dermatitis and a nonspecific dermatitis. He further indicated that the limits of medical knowledge had been exhausted, see Jones v. Shinseki, 23 Vet. App. 382 (2010). The Board finds that the Veteran is competent and credible to describe the symptoms of his skin disability and their onset. His statements compared with the medical evidence is at least in equipoise as to whether the Veteran has a skin disability or disabilities, seborrheic dermatitis and a nonspecific dermatitis, related to service. Accordingly, resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence supports a grant of entitlement to service connection for a skin disability. See 38 U.S.C.A. 5107(b), 38 C.F.R. §§ 3.102, 3.304; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). ORDER Entitlement to service connection for a right leg disability, other than gout, foot, and ankle disabilities, is denied. Entitlement to service connection for a left leg disability, other than gout, foot, and ankle disabilities, is denied. Entitlement to service connection for dermatitis is granted. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs