Citation Nr: 1323273 Decision Date: 07/22/13 Archive Date: 08/01/13 DOCKET NO. 12-04 504 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a left knee disorder. 2. Entitlement to service connection for a right knee disorder. 3. Entitlement to service connection for an acquired psychiatric disorder. 4. Entitlement to service connection for hearing loss disability. 5. Entitlement to service connection for migraine headaches. 6. Entitlement to service connection for type II diabetes mellitus. 7. Entitlement to service connection for right foot peripheral neuropathy, to include as secondary to type II diabetes mellitus. 8. Entitlement to service connection for left foot peripheral neuropathy, to include as secondary to type II diabetes mellitus. 9. Entitlement to service connection for hypertension, to include as secondary to type II diabetes mellitus. 10. Entitlement to service connection for a chronic pain disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD David S. Nelson, Counsel INTRODUCTION The Veteran had active service from January 1977 to December 1979. These matters come before the Board of Veterans' Appeals (BVA or Board) from a January 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. Pertinent VA medical records have been added to the claims file (uploaded to the Veteran's electronic Virtual VA folder) subsequent to the February 2012 statement of the case. The Veteran, through his representative, has waived initial RO consideration of this evidence. See Statement dated December 2012. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. There has been no demonstration by competent clinical evidence, or credible lay evidence, that a chronic left knee disorder was present in service, that left knee arthritis was demonstrated to a compensable degree within a year of discharge from service, or that there is a nexus or link between left knee arthritis and the Veteran's active service. 2. There has been no demonstration by competent clinical evidence, or credible lay evidence, that a chronic right knee disorder was present in service, that right knee arthritis was demonstrated to a compensable degree within a year of discharge from service, or that there is a nexus or link between right knee arthritis and the Veteran's active service. 3. Competent clinical evidence of record establishes a current diagnosis of PTSD due to an inservice stressor. 4. There has been no demonstration by competent clinical evidence, or credible lay evidence, that bilateral hearing loss was present in service or within one year thereafter, and the preponderance of the evidence fails to establish a nexus or link between bilateral hearing loss disability and the Veteran's active service. 5. There has been no demonstration by competent clinical evidence, or credible lay evidence, that a migraines headache disability was present in service, that an organic disease of the nervous system was demonstrated to a compensable degree within a year of discharge from service, or that there is a nexus or link between migraine headaches and the Veteran's active service. 6. There has been no demonstration by competent clinical evidence, or credible lay evidence, that diabetes was present in service, that diabetes was demonstrated to a compensable degree within a year of discharge from service, or that there is a nexus or link between diabetes and the Veteran's active service. 7. Right foot peripheral neuropathy was not present in service or demonstrated to a compensable degree within a year of discharge from service; a VA examiner has linked the Veteran's right foot peripheral neuropathy to nonservice-connected type II diabetes mellitus. 8. Left foot peripheral neuropathy was not present in service or demonstrated to a compensable degree within a year of discharge from service; a VA examiner has linked the Veteran's left foot peripheral neuropathy to nonservice-connected type II diabetes mellitus. 9. There has been no demonstration by competent clinical evidence, or credible lay evidence, that hypertension was present in service or within a year of discharge from service; and there is no evidence establishing a nexus or link between the Veteran's current hypertension and his active service. 10. A disability manifested by chronic pain has not been diagnosed/established at any time since, or just prior to, when he filed his claim in July 2010. CONCLUSIONS OF LAW 1. The criteria for service connection for left knee disability have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. The criteria for service connection for right knee disability have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. The criteria for service connection for PTSD with depression and anxiety has been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 4. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2012). 5. The criteria for service connection for migraines headaches disability have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 6. The criteria for service connection for type II diabetes mellitus have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 7. The criteria for service connection for right foot peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 8. The criteria for service connection for left foot peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 9. The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 10. The criteria for service connection for a chronic pain disability have not been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). (CONTINUED NEXT PAGE) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Duty to Notify Proper notice from VA must inform the claimant and representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. The Veteran was notified via a letter dated in August 2010 of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates if service connection is awarded. The Veteran has not been informed, via RO correspondence, of the criteria for establishing service connection on a secondary basis. The Board notes that the Veteran had no service-connected disability at the time he filed this claim in July 2010. At any rate, not all notice errors require corrective action. Rather, the question is whether 38 C.F.R. § 19.9 requires that the matter be remanded for correction of the error as such action is essential for a proper appellate decision. This the Board views in light of the rule of prejudicial error, which provides that if the error is not prejudicial to the claimant, it is harmless error and therefore requires no correction. See generally Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (explaining the rule of prejudicial error in the context of claims for VA benefits). Here, the Veteran was provided with a statement of the case in February 2012 that included the regulatory text (38 C.F.R. § 3.310) explaining to him what is required for grants of secondary service connection. A person reading this document would understand what was required to substantiate the secondary service connection claim. Based on the foregoing, together with the opportunity that the Veteran has had to meaningfully participate in the processing of this matter, that is, to offer argument and to submit evidence or request that VA obtain evidence, the Board finds that there has been no prejudice to the Veteran resulting from the defects in VCAA notice concerning secondary service connection claims and that a remand is not necessary to inform the Veteran of that which a person would already understand given the facts of this case. As VCAA notice was not completed prior to the initial AOJ adjudication of the claims, such notice was not compliant with Pelegrini. However, as the case was readjudicated thereafter, there is no prejudice to the Veteran in this regard. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Duty to Assist Service treatment records are associated with the claims file, as are identified VA and private medical records. Records from the Social Security Administration (SSA) are also of record. No outstanding records have been indentified that have not otherwise been obtained. The Veteran has undergone VA examinations to address the issues on appeal. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). With respect to the issues of service connection for a left knee disability, hearing loss, headaches, chronic pain, and peripheral neuropathy, the Board finds that the VA opinions obtained in this case are more than adequate. The opinions considered the pertinent evidence of record, the Veteran's personal/lay history, and provided a rationale for its conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Recognition is given to the fact that the aforementioned VA examinations did not directly address the etiology of the Veteran's diabetes mellitus, hypertension, and right knee disability. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The lack of a nexus opinion suggests inadequacy. However, the Board finds that the examinations were sufficiently adequate, and that no useful purpose would be served in Remanding these issues for an additional medical opinion. Specifically, as will be discussed in greater detail below, the evidence does not show complaints, treatment, or diagnosis of hypertension or diabetes mellitus (or symptoms related thereto) in service or for many years thereafter. The Veteran has not even provided any salient argument as to how these disabilities may be related to service. Both disabilities were not shown until at least 20 years after service. In short, given this evidentiary record, any opinion solicited from a VA examiner would be speculative in nature. Similarly, with regard to the Veteran's right knee disability, there is no evidence of inservice accident or injury. There is also an absence of treatment for right knee complaints until many years thereafter. Further, while he vaguely claims that his current right knee arthritis is due to the stresses and strains of active service, there is already ample evidence suggesting that his right knee arthritis is due to a post service injury. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). Applicable Laws-Service connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection for certain specified chronic diseases, such as arthritis, a psychosis, diabetes mellitus, hypertension, and organic diseases of the nervous system such as sensorineural hearing loss, migraine headaches, and peripheral neuropathy may be established on a presumptive basis by showing that such disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. Secondary service connection may also be granted for a disability, which is proximately due to, the result of, or aggravated by, an established service-connected disorder. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Secondary service connection includes instances in which an established service-connected disorder results in additional disability of another condition by means of aggravation. Allen. VA is required to evaluate the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the veteran served, the veteran's military records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). The Board notes that although all the evidence has been reviewed, only the most salient and relevant evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). I. Left knee A March 1978 service treatment record indicates that the Veteran twisted his left knee while skiing. The Veteran complained of pain in the medial aspect in the left knee. Examination revealed that the knees were stable to varus and valgus stress testing, bilaterally. The left medial collateral ligament (MCL) had mild tenderness. The assessment was first degree sprain of the left MCL. The Veteran was treated with an ace wrap. The Veteran's November 1979 service separation examination revealed that no musculoskeletal or lower extremity disability was noted on clinical examination. An August 1992 private treatment record noted that the Veteran was involved in an accident that resulted in the Veteran "slamming" the anterior aspect of his left knee on the dashboard of his vehicle. While X-rays taken thereafter were normal, a May 1993 left knee MRI revealed localized cartilage defect of the medial femoral condoyle, and findings consistent with chondromalacia. A September 1994 private treatment record reflects that the Veteran indicated that he had no left knee symptoms prior to the August 1992 automobile injury. In an August 1998 private record the Veteran complained of bilateral knee pain. The Veteran stated that he had sustained injuries to his left knee in a 1992 motor vehicle accident. The assessment was bilateral knee arthritis. At a November 2010 VA examination the Veteran stated that he had a gradual onset of bilateral knee pain during service. He said the symptoms came on gradually as a result of marching and running during service. His current symptoms included bilateral knee pain, swelling, and stiffness. X-rays of the knees revealed bilateral degenerative joint disease. The diagnosis was degenerative arthritis, both knees. A May 2011 private medical record noted that the Veteran had complaints of bilateral chronic knee pain. The assessment was bilateral osteoarthritis of the knees. The examiner described that the Veteran's knee arthritis was "progressive degenerative wear and tear" disease. In February 2012 a VA physician reviewed the Veteran's claims file and noted that other than the Veteran's March 1978 complaints, the remaining service treatment records were silent for any other left knee complaints or diagnoses. The examiner also noted that the record was silent for any left knee complaints from 1979-1992, and noted that there was "overwhelming" documentation that in August 1992 the Veteran had sustained a left knee work injury that had developed into left knee complaints that resulted in left knee degenerative joint disease. The examiner stated that the Veteran's left knee disability was not related to service but was related to the August 1992 vehicle accident. VA and private medical records confirm that the Veteran has a current left knee disability, degenerative arthritis, and such is not in dispute. However, as there is no evidence of left knee arthritis demonstrated to a compensable degree within the first year of service discharge, the presumption of service connection under 38 C.F.R. § 3.309(a) is not warranted. The Veteran's service treatment records do not tend to show that the Veteran's left knee arthritis had its onset during service. A March 1978 service treatment record indicates that the Veteran did suffer a left MCL sprain. However, no other complaints of left knee pain were made during his remaining service and no left knee disability noted on the November 1979 service discharge examination. The service treatment records dated subsequent to March 1978 do document, however, the Veteran seeking treatment for other health issues including diarrhea and problems of the eyes and ears. It is reasonable to assume that the Veteran would have sought out treatment for his left knee had the complaints of pain persisted. As for post-service medical evidence, the private and VA records do not show or contain any evidence suggesting a relationship between left knee disability and the Veteran's service. If anything, such records tend to show that the Veteran's left knee disability is related to the August 1992 motor vehicle accident referenced in those records. The February 2012 VA physician's opinion specifically stated that the Veteran's left knee disability was not related to the Veteran's military service. The February 2012 VA physician's opinion is evidence against the Veteran's claim. The Board affords the February 2012 VA physician's opinion considerable probative value because the examiner provided a compelling and logical rationale for the ultimate conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (explaining that most of the value of a medical opinion comes from its reasoning). Further lending weight to the February 2102 VA physician's opinion is the fact that he made specific references to findings from multiple clinical records associated with the claims file. Consideration has been given to the Veteran's assertions that his current left knee disorder is the result of the aforementioned in-service injury. However, while 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, an orthopedic, such as arthritis, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Arthritis is not the type of conditions that are readily amenable to mere lay diagnosis or probative comment regarding their etiology, as the evidence shows that an X-ray study and other specific findings are needed to properly assess and diagnose the disorder. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that Veteran is competent to report symptoms of knee pain, there is no indication that the Veteran is competent to etiologically link his in-service knee injury (MCL strain) to his current arthritis, which was diagnosed many years after service. It is true that the Veteran served as a medic and ambulance driver, and that he received some level of medical training. However, the Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating orthopedic disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). His post-service employment has not been in medical field. He has worked in the construction and trucking industry. His opinion is also heavily outweighed by the above-referenced VA opinion. Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. As for continuity of symptomatology since service, the Board emphasizes that no left knee disability was noted at service discharge. The private medical records suggest that the Veteran's left knee complaints did not begin until August 1992 as a result of a motor vehicle accident. Significantly, a September 1994 private treatment record reflects that the Veteran indicated that he had no left knee symptoms prior to the August 1992 injury. The Veteran has not been consistent in reporting the onset of his left knee symptoms and his statements in this regard are not credible and do not provide reliable evidence of a continuity of left knee symptomatology since service. A review of the evidence has revealed that left knee arthritis did not have onset during his active service and was not caused by his active service. As the preponderance of evidence is unfavorable to the claim, the Board must deny the issue of entitlement to service connection for left knee disability. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. (CONTINUED NEXT PAGE) II. Right knee Service treatment records reveal no complaints or diagnoses relating to a right knee disorder. The Veteran's November 1979 service separation examination revealed that no musculoskeletal or lower extremity disability was noted on clinical examination. In an August 1998 private record the Veteran complained of bilateral knee pain. The Veteran stated that he had sustained injuries to both of his knees in a 1992 motor vehicle accident. He stated that in 1994 his right knee had started to become more painful. The assessment was bilateral knee arthritis. At a November 2010 VA examination the Veteran stated that he had a gradual onset of bilateral knee pain during service. He said the symptoms came on gradually as a result of marching and running during service. His current symptoms included bilateral knee pain, swelling, and stiffness. X-rays of the knees revealed bilateral degenerative joint disease. The diagnosis was degenerative arthritis, both knees. A May 2011 private medical record noted that the Veteran had complaints of bilateral chronic knee pain. The assessment was bilateral osteoarthritis of the knees. The examiner stated that the Veteran's knee arthritis was "progressive degenerative wear and tear" disease. Medical records reveal that the Veteran has right knee arthritis. However, as there is no evidence of right knee arthritis demonstrated to a compensable degree within the first year of service discharge, the presumption of service connection under 38 C.F.R. § 3.309(a) is not warranted. The Veteran's service treatment records reveal that a right knee disability was not noted in service. This is evidence that he had no injury or disease of his right knee during service or any symptoms of such and is therefore evidence unfavorable to his claim. The post service private medical records do not show or contain any evidence suggesting a relationship between a right knee disability and the Veteran's service, and the Veteran has not asserted that such a record exists. Significantly, no healthcare professional has provided an opinion suggesting that the Veteran's right knee arthritis is related to his active service. The evidence instead suggests that his right knee disorder has the same etiological origin as his left knee arthritis, which is trauma related to the August 1982 motor vehicle accident. As for continuity of symptomatology since service, the Board notes that no right knee disability was noted at service discharge. Further, the private medical records clearly reveal that the Veteran's right knee complaints did not began until, at the earliest, sometime around the time of the August 1992 motor vehicle accident. To the extent that he argues that the stresses and strains of active service caused his current right knee arthritis, the Board finds his statements are not competent evidence. While acknowledging that the Veteran served as a medic during service, the Veteran has not claimed or shown that he has had the requisite medical training to provide opinions concerning the etiology of orthopedic disabilities such as arthritis. His opinion in this regard is not competent evidence and is not favorable to his right knee claim. A review of the evidence has revealed that right knee arthritis did not have onset during his active service and was not caused by his active service. As the preponderance of evidence is unfavorable to the claim, the Board must deny the issue of entitlement to service connection for right knee disability. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. III. Acquired psychiatric disorder. The Veteran essentially contends that he developed a psychiatric disability as a result of experiencing and witnessing gruesome accident scenes while serving as part of an ambulance crew during service. In addition to the foregoing, service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (2012); 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. 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 that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2012); see Cohen v. Brown, 10 Vet. App. 128 (1997). For VA compensation purposes, 38 C.F.R. § 4.125 requires that all mental disorder diagnoses must conform to the Fourth Edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). The Veteran's service treatment records note no complaints or diagnosis related to a psychiatric disorder. The Veteran's November 1979 service separation examination revealed that no psychiatric disability was noted on clinical examination. A November 1992 private treatment record revealed that the Veteran complained of symptoms of depression, anger, and sleep difficulties. At an October 1993 private psychiatric evaluation the Veteran expressed anger and frustration at not being able to work and provide for his child. The diagnoses included Major depressive episode. At an October 2010 VA examination the Veteran indicated that he served as a medic and ambulance driver during service. He recalled significant distress during service, including performing CPR on people who did not survive. He also described working at fatal motor vehicle accidents, responding to electrocutions, and seeing the death of children. He also remembered responding to a train accident. The Veteran's current complaints included sleep problems and avoidance behaviors. He also complained of a recurring dream of a train accident he had participated in during REFORGER in 1978. The diagnosis included PTSD secondary to his duties as a medic and ambulance driver during service, and a depression disorder secondary to his PTSD. A VA psychiatrist has indicated that the Veteran has a diagnosis of PTSD. While the October 2010 VA psychiatrist did not go into detail concerning the DSM-IV criteria necessary to support a diagnosis of PTSD, the VA psychiatrist clearly possesses the requisite medical training, expertise, and credentials needed to render a PTSD diagnosis. Further, there is no indication that the October 2010 VA psychiatrist relied on any inaccurate medical history in rendering the Veteran's PTSD diagnosis. In fact, the October 2010 VA psychiatrist indicated that she had reviewed the Veteran's medical records, including those associated with his SSA claim. The Board also observes that a September 2011 VA record noted that the Veteran had completed PTSD classes. As for the Veteran's asserted stressors, the Board notes that the Veteran's DD 214 reflects that the Veteran was a medical specialist and that he received training in emergency medicine. He was also authorized to wear a Drivers Badge. Based on the available personnel records and the Veteran's statements, it is plausible that the Veteran experienced the events as described in his October 2010 VA psychiatric examination, events which in essence served as stressors in support of the Veteran's PTSD diagnosis. See 38 U.S.C.A. § 1154(a). Resolving doubt in the Veteran's favor, the Board finds that the record establishes a current diagnosis of PTSD due to an inservice stressor that has been verified by the objective evidence of record. Service connection for PTSD with associated depression is warranted. The Board notes that a few VA mental health treatment records have also noted a diagnosis of an anxiety disorder. Further, an April 2011 VA treatment record essentially indicated that the Veteran's anxiety symptoms were related to the Veteran's PTSD. To the extent that such a disorder exists, the Board finds that the anxiety disorder is a manifestation/symptom of the PTSD. Other than PTSD, depressive disorder, and anxiety disorder, the Veteran has had no other psychiatric disability at any time since, or just prior to, the time he filed his claim in July 2010. In sum, service connection for PTSD, depressive disorder, and anxiety disorder is warranted. IV. Hearing loss disability. The Veteran asserts that he has hearing loss as a result of exposure to weapons fire during service, to include while serving as a medic at firing ranges. In regard to claims specific to service connection for hearing loss, the Veterans Benefits Administration Adjudication Manual states that "Sensorineural hearing loss is considered an organic disease of the nervous system and is subject to presumptive service connection under 38 CFR 3.309(a)." M21-1MR III.iv.4.B.12.a. As such, service connection for sensorineural hearing loss (as an organic diseases of the nervous system) may be presumed, subject to rebuttal, if manifest to a compensable degree within the year after active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. § 3.307, 3.309. Moreover, the concept of continuity of symptomatology as clarified by Walker, Supra., is applicable in this case. As noted by the November 2010 VA examiner, the Veteran's hearing loss is sensorineural in nature. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The determination of whether a veteran has a service-connectable hearing loss is governed by 38 C.F.R. § 3.385, which states that hearing loss will be considered to be a "disability" when the threshold level in any of the frequencies 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; or the thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores are less than 94 percent. 38 C.F.R. § 3.385. The Veteran's October 1976 service enlistment examination noted that the Veteran's ears were normal. Audiometric findings were, in pertinent part, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 10 5 5 LEFT 15 10 15 15 15 A December 17, 1977 service treatment record noted that the Veteran had complained of difficulty in hearing the prior month. Examination revealed no abnormalities of the ears. It was recommended that the Veteran undergo an audiometric evaluation. A December 21, 1977 service treatment record noted that the Veteran complained of a high pitched tone in both ears, with pain. Audiometric results were normal, and an ENT referral was deemed unnecessary. An August 1978 service treatment record noted that the Veteran complained of an ear ache; the diagnosis was left ear otitis media. The Veteran's November 1979 service separation examination noted that the Veteran's ears were normal. Audiometric findings were, in pertinent part, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 0 0 10 LEFT 15 5 10 20 15 At a November 2010 VA audiological examination the Veteran indicated that he had been exposed to three years of weapons fire during service. He also reported that he had some occupational noise exposure as a construction worker. The reported audiometric findings demonstrated right ear and left ear hearing loss disability for VA purposes. 38 C.F.R. § 3.385. Based on the Veteran's audiometric testing undertaken during service, the examiner opined that it was less likely than not that current hearing loss was related to service. A March 2012 VA audiology consult contained no information discussing the Veteran's military service. Bilateral hearing loss, nor a medical finding of a chronic clinically significant change in hearing ability in the left ear or right ear was demonstrated during the Veteran's active service. Moreover, bilateral hearing loss "disability" for VA purposes was not demonstrated to a compensable degree within the first year of discharge from such service, and was not shown until November 2010, many years following service. Significantly, there is no competent medical opinion linking left ear or right ear hearing loss disability to service, and the November 2010 VA examiner indicated that the Veteran's left ear and right ear hearing loss was not likely related to his military service. As for the probative value of the November 2010 VA opinion, the Board observes that the examiner reviewed the Veteran's claims file and noted the Veteran's assertions concerning his hearing loss. The Board finds that the November 2010 VA examiner's opinion is probative and persuasive because it took into consideration the Veteran's medical records and history, his complaints, and provided a supporting rationale. The Veteran is competent to report noise exposure during his period of service, and as such is consistent with the circumstances of his service, such assertions are deemed to be credible and were in fact assumed by the November 2010 VA examiner. However, whether a layperson opinion as to a nexus or a diagnosis is competent evidence depends on the facts of the particular case. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). One factor for consideration is the complexity of the question to be determined. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (providing an example in footnote 4 that a layperson would be competent to diagnose a simple condition such as a broken leg but not competent to diagnose a form of cancer). Another factor is whether the question can be answered by personal observation alone. See Layno v. Brown, 6 Vet. App. 465, 496 (1994) explaining that a layperson is competent to report only that which he or she observed). To the extent that the Veteran argues that in-service noise exposure caused his current hearing loss, the Board finds his statements are not competent evidence. Taking the aforementioned Davidson, Jandreau, and Layno together leads the Board to the conclusion that the complexity of the question, such as whether asserted in-service noise exposure results in sensorineural hearing loss can not be determined by direct observation and is not a simple question. The Veteran has not claimed or shown that he has had the requisite medical training to provide opinions concerning the etiology of hearing loss disability. His opinion in this regard is not competent evidence and is not favorable to his claim. The Board finds that the Veteran's statements as to continuity of symptomatology since service are less than credible. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by the veteran). In this regard, the Board notes that the Veteran did not indicate that he had any hearing loss or ear problems at the time of his separation from service or until many years following service. The private medical records that have been submitted by the Veteran during the course of this appeal appear to contain few if any complaints of hearing loss disability. In view of the medical evidence to the contrary, the Board does not find that the Veteran's lay statements are sufficient to establish continuity of symptomatology of left ear or right ear hearing loss. In sum, service connection for left ear and right ear hearing loss is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence weighs against the claims, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). V. Migraine headaches. An August 1978 service treatment record indicated that the Veteran complained of a left ear ache. Although not entirely clear, it appears that the Veteran indicated that he had a headache as well. The impression was left ear otitis media. A September 1979 service treatment record noted that the Veteran had complained of transient headaches the prior two weeks. The assessment was tension headaches. A general physical examination was conducted by the SSA in August 1998. At that time, the Veteran made no reference to experiencing chronic headaches much less chronic headaches since service. His neurological examination was also within normal limits. At a November 2010 VA general medical examination the Veteran indicated that he had been having headaches since 1977. He stated that he had never seen a medical provider for his headaches. He indicated that he would have headaches approximately five to six times a month. He said that the headaches would resolve after 2-3 days but would sometimes be incapacitating for several hours. The diagnosis was migraine headaches. A September 2011 VA record noted that the Veteran complained of frontal headaches; there was no assessment related to headaches. A February 2012 VA physician reviewed the Veteran's claims file and noted that the November 2010 VA examiner had diagnosed the Veteran with migraine headaches, based "purely on the Veteran's subjective history." The February 2012 VA examiner opined that the Veteran had no chronic headache condition and no confirmed diagnosis of migraine headaches. The February 2012 VA examiner stated that the Veteran's history provided at the November 2010 VA examination had not been credible. In particular, the February 2012 examiner stated that it was inconceivable that an individual with a headache condition as severe and frequent as that described by the Veteran would not present to a medical provider for evaluation and treatment. The February 2012 VA examiner concluded by stating that there were no residuals from the Veteran's "two active duty headache episodes" and that the Veteran had no current chronic (migraine) headache condition. Even assuming the validity of the November 2010 VA examiner's diagnosis of migraine headaches, as there is no evidence of migraine headaches demonstrated to a compensable degree within the first year of service discharge, the presumption of service connection under 38 C.F.R. § 3.309(a) is not warranted. The Veteran's service treatment records do not tend to show that a migraine headaches disability had its onset during service. There is no indication that the Veteran had migraine headaches in service, and no headaches disability was noted at service discharge in November 1979. As for post-service medical evidence, the private and VA records do not show or contain any evidence suggesting a relationship between migraine headaches disability and the Veteran's service. In fact, the February 2012 VA physician's opinion specifically stated that the Veteran had no residuals from the complaints of headaches made during service. Even assuming that the Veteran is competent to state that he has a current headaches disability, and that he has had headaches since 1977, the Board finds that such assertions lack credibility. The Veteran has acknowledged that he never sought treatment for his headaches, headaches that he has described as sometimes lasting for hours and taking 2-3 days to resolve. It is not credible that the Veteran would be able to work as a truck driver or mover under such conditions. Further, it appears that the Veteran did not claim headaches as being part of the basis of his claim for disability when pursuing SSA disability benefits. He made no reference to headaches at that time and a contemporaneous neurological examination was essentially normal. Had he been having headaches as he claimed, the Board believes that he would have mentioned such when pursuing his SSA claim. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (where there is a lack of notation of medical condition or symptoms where such notation would normally be expected, the Board may consider this as evidence that the condition or symptoms did not exist). A review of the evidence has revealed that a chronic headaches disability did not have its onset during the Veteran's active service and was not caused by his active service. As the preponderance of evidence is unfavorable to his claim, the Board must deny his appeal as to entitlement to service connection for headaches disability. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. VI. Type II diabetes mellitus. The Veteran has provided little in the way of contentions concerning his diabetes and his military service. The Veteran's service treatment records note no complaints or diagnosis related to diabetes mellitus. The Veteran's November 1979 service separation examination revealed that no endocrine disability was noted on clinical examination, and urinalysis testing was negative. At a November 2010 VA examination the Veteran stated that he was first diagnosed with diabetes in 2000. The Veteran did not indicate that he had symptoms of diabetes in service. The Board finds that diabetes was not present in service and was not demonstrated to a compensable degree within a year of discharge from service. Further, there is no nexus or link between diabetes and the Veteran's active service. The Board must consider the credibility and competency of the Veteran's statements. While there appears to be no such statements to consider, the Board observes that to the extent that the Veteran argues that some in-service event or injury caused his diabetes mellitus, the Board finds his statements are not competent evidence. The Veteran has not claimed or shown that he has had the requisite medical training to provide opinions concerning the etiology of diabetes mellitus. His opinion in this regard is not competent evidence and is not favorable to his claim. A review of the evidence has revealed that diabetes did not have its onset during the Veteran's active service and was not caused by his active service. As the preponderance of evidence is unfavorable to his claim, the Board must deny his appeal as to entitlement to service connection for diabetes. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. VII. Right foot and left foot peripheral neuropathy At the November 2010 VA examination the Veteran indicated that he had pain in his feet associated with numbness since 2000 and had been diagnosed with diabetic polyneuropathy. Examination revealed decreased sensation in the bilateral lower extremities in a stocking distribution from the level of just above the ankles to the toes, bilaterally. The diagnosis was chronic, painful, bilateral lower extremity sensory polyneuropathy, as likely as not due to diabetes mellitus with no other causes found for the polyneuropathy. A VA examiner has linked the Veteran's polyneuropathy to the Veteran's nonservice-connected diabetes mellitus. The November 2010 VA examiner noted that the Veteran's polyneuropathy had no other cause. The Board notes in passing that the Veteran's service treatment records do not reflect any complaints or diagnoses related to lower extremity polyneuropathy, and the Veteran's November 1979 service separation examination reveals that his neurologic system was clinically evaluated as normal. The Veteran has not disputed that his polyneuropathy is linked to his diabetes mellitus. However, as service connection is not in effect for diabetes mellitus, service connection on a secondary basis is not for application. Further, as polyneuropathy was not shown in service or within one year thereafter, service connection for bilateral polyneuropathy on a direct basis must be denied. In this regard, the Board notes that records such as an August 1998 physical examination taken years following service noted that the Veteran's neurologic examination was normal. VIII. Hypertension The Veteran's service treatment records do not reflect any complaints or diagnoses of hypertension or heart disability. The Veteran's November 1979 service separation examination reveals that his heart was clinically evaluated as normal. His blood pressure was recorded as 130/84, which does not suggest hypertension. See Diagnostic Code 7101, Note (1) (2012) (the term hypertension means the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm). The earliest blood pressure readings of record include a December 1984 private anesthesia record indicating blood pressure readings of 144/100 and 121/84. Hypertension was not diagnosed, however. An August 1992 private medical record noted a blood pressure reading of 110/82. At a November 2010 VA examination the Veteran stated that he had been diagnosed with hypertension in 2000 and had been on medications since that time. Examination revealed blood pressure readings of 118/76, 118/78, and 118/76. The diagnosis was hypertension with no left ventricular hypertrophy or congestive heart failure. . In short, there is no evidence of a diagnosis of hypertension in service. There is also no objective evidence that the Veteran was diagnosed as having hypertension within one year of his service discharge. Elevated blood pressure readings have not been shown until, at the earliest, December 1984, approximately 5 years following service. A diagnosis of hypertension was not made until 2000. The Veteran is not competent to establish a matter that requires medical knowledge, such as providing the etiology of his hypertension. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Any assertion of continuity of symptomatology of hypertension is not supported by the record. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by the veteran). The Board notes that the Veteran has indicated that he was not diagnosed with hypertension until 2000; and, the Board can find no findings of any elevated blood pressure readings until 5 years subsequent to service. The Veteran has not provided any argument as to why his current hypertension is related to his active service. The criteria for service connection for hypertension are not met. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence weighs against the claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). IX. Chronic pain disorder. The existence of a current disability is the cornerstone of a claim for VA disability compensation. In the absence of proof of a present disability there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). It is important to note that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. Principi, 239 F. 3d 1356 (2001). The Veteran has not been diagnosed with a disability characterized as a chronic pain disorder. VA records such as the November 2010 general medical examination noted no such disorder, and, in the same manner, no such disability was noted in a May 2011 private treatment record that contained an extensive review of systems portion. While records such as a September 2011 VA treatment record note that the Veteran has been assessed with arthritis of the left hand, knees, and left shoulder, the Board can find no diagnosis of systemic arthritis or other such related disability. The Veteran, despite having had many chances to do so, has provided little in the way of assertions or contentions concerning this issue. At the November 2010 VA examination the Veteran essentially stated that his chronic pain was in reference to his bilateral knee pain and diabetic neuropathy of the feet. As the evidence does not show that the Veteran has a chronic pain disability, there is no basis upon which to grant service connection for this claim and it must be denied. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to diagnose a chronic, systemic pain disability. His lay evidence, to the extent that he has provided any, does not constitute competent medical evidence and lacks probative value. In sum, service connection for a chronic pain disorder is not warranted. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence weighs against the claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for a left knee disorder is denied. Service connection for a right knee disorder is denied. Service connection for PTSD and a depressive disorder is granted. Service connection for bilateral hearing loss is denied. Service connection for migraines headaches disability is denied. Service connection for type II diabetes mellitus is denied. Service connection for right foot peripheral neuropathy is denied. Service connection for left foot peripheral neuropathy is denied. Service connection for hypertension is denied. Service connection for a chronic pain disability is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs