Citation Nr: 1323765 Decision Date: 07/25/13 Archive Date: 08/06/13 DOCKET NO. 07-16 078 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability. 3. Entitlement to service connection for a back disability. 4. Entitlement to service connection for a skin condition. 5. Entitlement to service connection for bilateral hearing loss. REPRESENTATION Veteran represented by: Alabama Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran served on active duty from April 1969 to March 1971, including service in the contiguous waters of Vietnam. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which denied the benefits sought on appeal. In April 2012, the Veteran and his spouse appeared at a Travel Board hearing before the undersigned. A transcript of the hearing is of record. At his hearing, the Veteran submitted additional evidence, accompanied by a waiver of initial RO consideration. 38 C.F.R. § 20.1304(c) (2012). In February 2011 and October 2012, the Board remanded the instant claims for further development. The Board also remanded the issue of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder. In a February 2012 rating decision, the RO granted service connection for an acquired psychiatric disorder. Therefore, that issue is no longer on appeal. FINDINGS OF FACT 1. The Veteran's right knee disability was not shown in service or for many years thereafter and is not shown to be related to service. 2. The Veteran's left knee disability was not shown in service or for many years thereafter and is not shown to be related to service. 3. The Veteran is not shown to have a current low back disability during the appeal period. 4. Any current skin disability was not shown in service or for many years thereafter and is not shown to be related to service. 5. The Veteran's current hearing loss disability is not shown to be related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right knee disability are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for entitlement to service connection for left knee disability are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 3. The criteria for entitlement to service connection for low back disability are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). 4. The criteria for entitlement to service connection for skin disability are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 5. The criteria for entitlement to service connection for bilateral hearing loss are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.385 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the Veteran of any information and 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. See 38 C.F.R. § 3.159(b)(1). A January 2006 letter explained the evidence necessary to substantiate the claims and VA and the Veteran's responsibilities. The letter also informed the Veteran of his and VA's respective duties for obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). A subsequent March 2011 letter explained how a disability rating is determined and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). After the issuance of these letters, the case was readjudicated by February 2012 and January 2013 supplemental statements of the case. Thus, the Veteran was not prejudiced by the timing of the latter March 2011 notice. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). With regard to the duty to assist, the claims file contains the service treatment records, VA treatment records, private treatment records, the reports of VA examinations pertaining to the claim for service connection for hearing loss, and the assertions of the Veteran, his wife and his representative. The May 2011 VA audiological examination and June 2011 supplemental opinion were adequate because they were based on a thorough examination, a description of the Veteran's pertinent medical history, a complete review of the claims folder, and appropriate diagnostic tests. The examiner also provided a rationale for the opinion. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) The Board notes that pursuant to the October 2012 remand, the Appeals Management Center (AMC) contacted the Veteran via a November 2012 letter and requested that he provide release of information forms so the AMC could attempt to obtain records from a Dr. Funderburke for the time frame prior to May 2001; all treatment records from a Dr. Brackin, including records dated in 1983 related to an open reduction internal fixation of a lateral tibial plateau fracture and any disability records from the Railroad Retirement Board. However, the Veteran did not return any of the releases. The duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190 (1991). Because the appellant has not cooperated with the AMC in providing enough information to enable VA to obtain these records on his behalf, no further action is necessary on VA's part. 38 C.F.R. § 3.159. The RO also attempted to obtain the Veteran's records from the Social Security Administration (SSA). In March 2011, the RO received a response from SSA indicating that no medical records existed for the Veteran. Regarding the Veteran's hearing before the Board, 38 C.F.R. 3.103(c)(2) requires that a VLJ chairing a hearing fulfill two duties to comply with this VA regulation. These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the Veteran's October 2008 hearing, all parties agreed as to the issues on appeal, including the issues herein decided. The parties also discussed evidence currently contained in the record and what pertinent evidence might still be outstanding. Additionally, the Board's subsequent remands further instructed the RO/AMC to obtain outstanding VA records, to attempt to obtain any appropriately identified additional private treatment records and to afford the Veteran with a VA examination pertaining to his claim for bilateral hearing loss. As noted above, the Veteran did not respond to the November 2012 RO/AMC letter by submitting any releases of information or affirmatively submitting any of the sought after records. Thus, VA has not been able to obtain the additional records sought by the October 2012 remand and the Board presumes that the Veteran does not have any further evidence to submit. Consequently, the Board finds that the Board's duties under Bryant have been met. Further, to the extent there were any shortcomings, the Veteran was not prejudiced, given that he has not empowered VA to attempt to obtain the additional information noted in the October 2012 remand and has not otherwise indicated that there is any further outstanding evidence pertinent to his claim. The Board has also considered whether a VA medical examination is necessary for proper adjudication of the Veteran's claims for service connection for a bilateral knee disability, back disability and skin disability. As explained in the analysis below, the Board does not find credible the Veteran's essential allegations of continuity of knee, low back and skin pathology since service. Consequently, the evidence does not meet even the low threshold of indicating that the current knee disabilities or any current low back or skin symptomatology may be associated with any established event, injury, or disease in service or with another service-connected disability. See 38 C.F.R. § 3.159(c)(4). Further, with regard to his low back disability claim, as will be explained below, the Veteran has not been shown to have a current low back disability at any time during the pendency of the appeal. Therefore, because there is no current disability that could be related to an event, injury, or disease in service, the Board finds that a VA examination is unnecessary. 38 C.F.R. § 3.159(c)(4)(i); cf. Duenas v. Principi, 18 Vet. App. 512, 517 (2004), citing Paralyzed Veterans of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334, 1355-57 (Fed. Cir. 2003) (noting that a medical examination conducted in connection with claim development could not aid in substantiating a claim when the record does not already contain evidence of an in-service event, injury, or disease). See also Waters v. Shinseki, 601 F. 3d 1274, 1278 (Fed. Cir. 2010) (noting that a veteran's conclusory generalized statement that a service illness caused his present medical problems was not enough to entitle him to a VA medical examination since all veterans could make such a statement, and such a theory would eliminate the carefully drafted statutory standards governing the provision of medical examinations and require VA to provide such examinations as a matter of course in virtually every disability case). For the reasons discussed above, the Board is also satisfied that there was substantial compliance with its February 2011 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has not made the RO or the Board aware of any additional evidence that must be obtained in order to fairly decide the appeal. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Bilateral knee disability The Veteran has alleged that his knees first started bothering him in service during boot camp and that they have continued to bother him ever since. The Veteran's service treatment records do not show any findings or complaints of right or left knee pathology. At his March 1971 separation examination, the lower extremities were found to be normal and no knee pathology was noted. A June 2000 private progress note shows that the Veteran complained of arthritis in the right knee with pain with movement. The diagnostic impression was arthritis of the right knee. A June 2000 right knee X-ray showed no definite acute findings. A chronic defect was seen in the lateral tibial plateau along the articular surface and two screws transfixed a nonacute fracture. At a May 2001 visit with Dr. Funderburke, the Veteran complained of right knee pain on and off for a number of years. Examination showed slight instability and no direct tenderness. The Veteran reported mild pain on motion. The diagnostic assessment was right knee pain. A May 2001 private progress note from Alabama Orthopedics shows that the Veteran reported a long history of worsening right knee pain. It was noted that he had had an open reduction internal fixation operation in 1983 for a tibial plateau fracture in 1983. Over the last several years, the knee had gotten progressively worse. It would swell intermittently. There was a lot of lateral joint line tenderness and he had a popping sensation in the area. The examiner thought that there was a large lateral PLICA (i.e. intraarticular fold of the joint lining, or synovial tissue, over the medial aspect of the knee) and one of the Veteran's screws was a little prominent. There was no medial joint line tenderness. There was a mild amount of tenderness over the right medial and lateral facets of the patella that was greater laterally. The Veteran had full flexion and pain on extremes of flexion. He lacked a couple of degrees of full extension. X-rays showed some very slight tilting of the patella with two threaded large screws, upper lateral and medial. There was a healed tibial plateau fracture. There was a fair amount of arthritis in the lateral tibial plateau. In December 2002, the Veteran was again examined for pain in the right knee on movement. The diagnostic impression was right knee arthritis. The Veteran also complained of pain in the left knee. At a June 2007 VA primary care visit, the Veteran reported pain in the knees for years that was getting worse. He gave a history of degenerative joint disease of the knees since after the military, sometimes with instability, which was present more on the right. The Veteran had been treated with sulindac but quit taking this due to his hypertension and coronary artery disease. Physical examination showed musculoskeletal pain with right knee flexion. The Veteran was referred for an X-ray and MRI. June 2007 bilateral knee X-rays showed no bony abnormality on either side. There was hardware in the proximal end of the tibia on the right, presumably from a reduction of an old fracture. At a June 2007 MRI screening, the Veteran reported that he had had right knee surgery in 1972 and that 2 pins were placed in the knee. At a July 2007 VA physical therapy consultation, the Veteran reported that the pins were put in the right knee in 1973. He reported current buckling and locking in the knees, along with night pain and daily swelling by midday. A July 2007 VA MRI of the right knee produced a limited evaluation due to artifact from orthopedic hardware. There was joint effusion. Some fibers of the ACL were seen, which excluded a complete tear. The menisci, MCL and LCLs could not be evaluated. At a March 2008 VA physical therapy consultation, the Veteran reported periodic knee swelling, pain and buckling. The buckling was mostly in the right knee and had caused falls, the last one three or four weeks previously when he was walking without his cane. Six weeks of fee basis physical therapy was prescribed. April to July 2008 private physical therapy records show that the Veteran received treatment for the right knee. The diagnosis was right knee pain. At an April 2009 VA pain assessment, the Veteran reported that he had had low back and leg pain for years. At a May 2009 VA primary care visit, the Veteran reported knee pain and low back pain on the left side. At the April 2010 Board hearing, the Veteran reported that he first began having problems during boot camp. They would swell up after a day of marching and he would have to go to sick call. He indicated that he also had problems with the knees during his Vietnam service but he did not go to sick call because he was simply too scared during that time period. He reported that he went to see a Dr. Rennings and a Dr. Moore for his knee problems just after service but these physicians had since passed away. He indicated that these physicians informed him that the cushioning between his knee joints was wearing away. He also indicated that he subsequently had the pins placed in the right knee. He indicated that he subsequently saw a Dr. Johns and then a Dr. Funderburke for his knee problems. Dr. Funderburke took some X-rays and then referred the Veteran to a specialist. He indicated that he had been going to Dr. Funderburke for years. He was not sure exactly when he started seeing him but he thought that it was sometime after 1976. He thought that records from that time frame were not available. A June 2010 VA primary care progress note shows that the Veteran reported having right knee surgery in 1973. He reported chronic pain in the back and the knees. He indicated that the low back pain radiated to the legs. Physical examination showed painful range of motion of the spine and the shoulders and crepitus in both knees. The pertinent diagnostic assessment was chronic pain, probably from degenerative arthritis. At a subsequent August 2010 visit, the Veteran reported that he needed a knee replacement. He did not want an orthopedic consultation or follow-up X-rays because of his financial constraints. At a November 2010 visit, it was noted that the Veteran had degenerative arthritis and chronic right knee pain. At an April 2011 visit, he reported continued back pain. Physical examination showed painful range of motion of the spine. As noted above, the Veteran's service treatment records are negative for any clinical reference to right or left knee pathology. The medical evidence of record then does not contain any indication of manifestation of any knee pathology prior to 1983, 12 years after service, the point which the Veteran has reported to medical practitioners that he underwent the open reduction, internal fixation (ORIF) procedure for his tibial fracture. Moreover, none of the post-service medical records contain any indication that the Veteran's current bilateral knee disability, diagnosed as arthritis, noted so many years after separation, is related to such service. A lengthy interval of time between service and initial postservice manifestation of a "disability" for which service connection is sought is, of itself, a factor against a finding that the disability was incurred or aggravated in service. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The Veteran has contended that his knees started to bother him during service and have continued to bother him ever since. Arthritis is a chronic condition as set forth in 38 C.F.R. § 3.303(a). Therefore, the theory of continuity of symptomatology is not applicable in this case. 38 C.F.R. § 3.303(a),(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). He has also contended that he was informed by a physician soon after service that the cushioning between his knee joints was wearing away. He is competent to make such assertions, and if credible, such testimony constitutes supporting evidence that a nexus may be present between his current knee disabilities and service and also that arthritis may have been present within the first post-service year. The Board notes, however, that the Veteran initially filed his claims for service connection for knee disabilities in December 2005. Subsequently, during June and July 2007 VA medical visits, he reported that he received surgery with placement of two pins in his right knee in 1972/1973. However, the May 2001 Alabama Orthopedic record later associated with the claims file affirmatively shows that the Veteran reported that his surgery, for a right tibial plateau fracture, occurred in 1983. Also, neither the May 2001 Alabama Orthopedic record nor the other medical evidence of record, pertaining to the time frame prior to when the Veteran filed his claim for service connection, shows any indication that the Veteran had any right or left knee problems during service or at any time prior to 1983. Additionally, the service treatment records do not show that the Veteran received any medical attention for right or left knee problems during service, despite his assertion that he did go to sick call on at least one occasion for such problems. At his March 1971 separation examination, his lower extremities were found to be normal and no knee symptoms or disabilities were noted by the examining physician. The Veteran's pre-separation physical examination is particularly probative both as to the Veteran's subjective reports and their resulting objective findings. It was generated with a view towards ascertaining the Veteran's then-state of physical fitness and are akin to statements of diagnosis or treatment. Rucker v. Brown, 10 Vet. App. 67, 73(1997) (Observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision); see also LILLY'S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rationale that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). Further, the Veteran did not submit the release of information forms necessary to allow VA to obtain any additional evidence that might provide more detail on whether the Veteran's history of knee problems dates back to his military service. Regarding the specific reporting of the right tibial surgery, the Veteran's initial report, made in 2001, that the surgery occurred in 1983, is significantly more contemporaneous to the actual event and was made against the Veteran's interest in receiving compensation for knee disability. Thus, the Board credits it over his later report, made only after he had filed a claim for compensation that the surgery occurred very soon after service in 1972 or 1973. Consequently, the evidence tends to indicate that the Veteran experienced a highly traumatic injury to his right knee (i.e. a tibial plateau fracture) sometime around 1983, more than 10 years after separation. The Veteran's lack of specific credibility concerning the timing of the surgery also tends to weigh against crediting his report of continuity of right and left knee symptomatology since service. Additionally, the lack of any evidence in the service treatment records of any complaints or findings of right or left knee pathology and the lack of any mention of any history of right or left knee problems dating back to service in the medical evidence of record that is dated prior to the Veteran's December 2005 service connection claim, also weighs against the credibility of this report of continuity. Moreover, the Veteran's failure to authorize VA to attempt to obtain evidence that might provide additional illumination of his bilateral knee treatment history since service is also considered a factor weighing against his credibility. Thus, considering all of this information together, the Board does not find credible the Veteran's report of right and left knee pathology since service and does not find credible the Veteran's report of the physician finding soon after service that the cushioning between his knee joints was wearing away. Accordingly, these reports have no probative value. Further, to the extent that the Veteran is alleging that his current left or right knee disability is otherwise related to service, as a layperson he is not competent to provide a medical opinion regarding such a medical nexus. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, whether his current bilateral knee disability was caused by his period of active service, 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). Consequently, given that there is no competent medical evidence of right or left knee disability until many years after service; given that there is no competent evidence of a nexus between the Veteran's current right and left knee disabilities and service and given that the Veteran's report of continuity of symptomatology since service is not credible, the weight of the evidence is against a finding of service connection on either a direct or presumptive basis. 38 C.F.R. § 3.303, 3.307, 3.309. The preponderance of the evidence is against these claims and they must be denied. Back disability The Veteran has alleged that he first started experiencing low back pain during service and that his back has continued to bother him ever since. The service treatment records do not show any findings or complaints of low back pathology. At his March 1971 separation examination, the spine was found to be normal and no low back pathology was noted. An October 2001 private progress note from Dr. Funderburke shows that the Veteran was complaining of back pain that started one week prior. The diagnostic assessment was back pain. At a September 2004 private medical visit, the Veteran reported that he cut a tree and it subsequently fell across his left posterior ribs, causing pain in the area. The pertinent diagnosis was abrasion to the back with flank pain. At an April 2009 VA pain assessment, the Veteran reported that he had had low back and leg pain for years. At a May 2009 VA primary care visit, the Veteran reported knee pain and low back pain on the left side. At a July 2010 VA medical visit, the Veteran reported back pain radiating toward the front. The diagnostic assessment was right flank pain. During the April 2010 Board hearing, the Veteran reported that he had back pain in service from carrying his gun and ammunition. He thought that this was normal because of all the weight he had to carry. Consequently, he never went to sick call for the pain. He indicated that he received treatment soon after service for back problems from a Dr. Rennings and a Dr. Moore. At an April 2011 VA primary care visit, the Veteran was continuing to complain of back pain. It was noted that he had had physical therapy treatment previously. The Veteran was found to have painful range of motion of the spine. In the instant case, the Veteran is not shown to have a current low back disability. He has affirmatively been noted to have low back pain. However, 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. West, 13 Vet. App. 282, 285 (1999). Without a showing of a current, chronic low back disability, service connection for such disability may not be granted. See Brammer v. Derwinski, 3 Vet. App. 223 (1992) (In the absence of proof of current disability, there can be no valid claim of service connection). Also, even if the Veteran were shown to have a current low back disability, a nexus to service has not been established. The Veteran has essentially contended that his low back started to bother him during service and has continued to bother him ever since. Because he has not been diagnosed with arthritis, he does not have a chronic back condition as set forth in 38 C.F.R. § 3.303(a). Therefore, the theory of continuity of symptomatology is not applicable in this case. 38 C.F.R. § 3.303(a),(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Direct service connection is not warranted. Although he is competent to report observable symptoms, given his lack of credibility in his reporting of the timing of his right knee surgery, his reporting of the timing of his low back pathology must also be called into question. Also, the Veteran's separation examination shows that the spine was found to be normal. Additionally, the post-service medical evidence, particularly the evidence prior to the Veteran filing for service connection, does not include any specific report by the Veteran that he had been experiencing back problems since service and does not include any objective findings of low back pathology any earlier than October 2001. To the contrary, the October 2001 private progress note from Dr. Funderburke shows a history of back pain starting only one week prior. Further, the Veteran did not submit the release of information forms necessary to allow VA to obtain any additional evidence that might provide more detail on whether his history of low back problems dates back to his military service. Thus, considering all of this information together, the Board does not find credible the Veteran's essential report of continuity of low back pathology since service. Accordingly, the report has no probative value. Further, to the extent that the Veteran alleges that any current low back disability is otherwise related to service, although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, as to the specific issue in this case, whether he has a low back disability that was caused by his period of active service, falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4 (Fed. Cir. 2007). Consequently, given that a current, chronic low back disability has not been established; given there is no competent medical evidence of any low back problems until many, many years after service; given that there is no competent evidence of a nexus between any current low back problems and military service; and given that the Veteran's report of continuity of symptomatology since service is not credible, the weight of the evidence is against a finding of service connection on either a direct (or presumptive) basis. 38 C.F.R. § 3.303, 3.307, 3.309. The preponderance of the evidence is against this claim and it must be denied. Skin condition The Veteran alleges that he began to experience a rash during the tail end of his military service and that it has continued to bother him periodically ever since. The service treatment records do not show any findings or complaints of skin pathology. At his March 1971 separation examination, his skin was found to be normal. A January 2002 private progress note from Dr. Funderburke shows that the Veteran was complaining of a wart on the face. At a February 2004 private medical visit, the Veteran reported moles on the face and left hip accompanied by burning and itching. The pertinent diagnosis was skin lesions of the face and left hip. During the April 2010 Board hearing, the Veteran reported that Dr. Rennings and Dr. Moore treated him for his skin rash soon after service. For the rash, he was informed that the best treatment was actually Secret women's deodorant. The Veteran indicated that he did first experience his rash in service, just before he was discharged. He reported that he did not go to the doctor at the time as he was just thinking that the rash was caused by the heat and that it would clear. At a May 2010 private medical visit, the Veteran was found to have a skin lesion to the left face. As noted above, the Veteran's service treatment records are negative for any reference to skin pathology. The medical evidence of record does not contain any indication of manifestation of any skin pathology prior to 2002, approximately 31 years after service. Moreover, none of the post-service medical records contain any indication that any current skin problems noted so many years after separation are related to such service. A lengthy interval of time between service and initial postservice manifestation of a "disability" for which service connection is sought is, of itself, a factor against a finding that the disability was incurred or aggravated in service. See Maxson, 230 F.3d 1330 (Fed. Cir. 2000). The Veteran has contended that he began to have skin problems during service and that he is continued to have them ever since, at least intermittently. His skin condition is not a chronic condition as set forth in 38 C.F.R. § 3.303(a). Therefore, the theory of continuity of symptomatology is not applicable in this case. 38 C.F.R. § 3.303(a),(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Direct service connection is not warranted. Although he is competent to report observable symptoms, given his lack of credibility in his reporting of the timing of his right knee surgery, his reporting of the timing of his skin pathology must also be called into question. Also, the Veteran's separation examination shows that the skin was found to be normal. Additionally, the post-service medical evidence does not include any specific report by the Veteran that he had been experiencing skin problems since service and does not include any objective findings of skin problems any earlier than 2002. Further, the Veteran did not submit the release of information forms necessary to allow VA to obtain any additional evidence that might provide more detail on whether the Veteran's history of skin problems dates back to his military service. Thus, considering all of this information together, the Board does not find credible the Veteran's assertion that his skin condition is related to service. Accordingly, the report has no probative value. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, whether his current skin condition was caused by his period of active service, 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). Consequently, given there is no competent medical evidence of any skin problems until many, many years after service; given that there is no competent evidence of a nexus between any current low back problems and military service; and given that the Veteran's report of continuity of symptomatology since service is not credible, the weight of the evidence is against a finding of service connection. 38 C.F.R. § 3.303. The preponderance of the evidence is against this claim and it must be denied. Hearing loss The Veteran alleges that his current hearing loss is related to noise exposure in service. The Veteran's DD-214 shows that his military occupational specialty (MOS) was machine gunner. The Veteran's service treatment records do not show any findings or complaints of hearing loss. At his April 1968 pre-induction examination, pure tone audiometry showed hearing within normal limits. At his March 1971 separation examination, whispered and spoken voice testing was 15/15 bilaterally. The Board notes that whispered and spoken voice hearing tests are not necessarily sufficiently sensitive to rule out the presence of a high frequency impairment. See Godfrey v. Brown, 8 Vet. App. 113 (1995). A January 2007 private audiogram showed hearing loss in both ears. A January 2007 VA audiological consultation showed mild to moderately severe sensorineural hearing loss. Hearing aids were ordered for the Veteran. At a January 2009 VA audiological evaluation, audiometry revealed that puretone thresholds (in decibels) were: HERTZ 500 1000 2000 3000 4000 RIGHT 35 45 55 65 65 LEFT 35 35 45 55 60 The average puretone thresholds were 58 decibels, right ear, and 49 decibels, left ear. Speech audiometry revealed that speech recognition was 68 percent in the right ear and 76 percent in the left ear. The diagnoses were moderately severe senosrineural hearing loss in the right ear and mild to moderately severe sensorineural hearing loss in the left ear. His level of hearing loss meets the threshold criteria to be considered a disability for VA purposes. 38 C.F.R. § 3.385. The Veteran reported bilateral hearing loss since approximately the early to mid 1970s. It was noted that military exposure was significant for artillery and combat noise while serving in Vietnam. The Veteran served as a gunner and was exposed to artillery, gunfire, explosions etc. and was not provided hearing protection. After military service, he was employed as a carpenter. He stated that he wore hearing protection at times. He also worked on cars on the side. He had hunted in the past with and without the use of hearing protection. He denied any other occupational or recreational exposure. He also reported that he first noticed tinnitus in the early 1970s. The examiner commented that at induction, audiometric testing indicated that hearing was within normal limits bilaterally. At separation, the Veteran passed a whispered voice test at 15 decibels bilaterally. The examiner noted that a whispered voice test could not rule out or identify high frequency hearing loss. Without frequency specific audiometric tests at or around the point of discharge, it was difficult to prove otherwise. The examiner also noted that the Veteran worked in a noisy environment after service without the use of hearing protection at times. Therefore, it was the examiner's opinion that it was less likely than not that hazardous military noise exposure contributed to the Veteran's level of hearing loss. At the April 2010 Board hearing, the Veteran testified that his military occupational specialty was machine gunner. He indicated that he first noticed hearing loss right after getting out of service. He noted that his basic occupation after service was carpenter. The Veteran's wife testified that over the years she had asked the Veteran to get his ears checked but that he had not done it until fairly recently. At a May 2011 VA audiological evaluation performed by the same audiologist who performed the January 2009 evaluation, audiometry revealed that puretone thresholds (in decibels) were: HERTZ 500 1000 2000 3000 4000 RIGHT 40 55 65 70 70 LEFT 35 50 60 65 70 The average puretone thresholds were 65 decibels, right ear, and 70 decibels, left ear. Speech audiometry revealed that speech recognition was 76 percent in the right ear and 70 percent in the left ear. The diagnosis was moderately to severe sensorineural hearing loss. The Veteran reported hearing loss present since approximately the early to mid 1970s. He indicated that he currently had difficulty understanding speech in all listening environments. The examiner essentially repeated the Veteran's history of noise exposure noted during the prior January 2009 VA evaluation. The Veteran reported that he had suffered from ear infections off and on over the past 30 years and had been treated with medication. The examiner noted that at induction, audiometric testing indicated hearing within normal limits bilaterally. At separation, the Veteran passed a whispered voice test at 15 decibels bilaterally. The examiner noted that the whispered voice test cannot rule out or identify high frequency hearing loss. Without frequency specific audiometric tests at or around the point of discharge, it was difficult to show the presence of hearing loss. The examiner noted that the Veteran had been exposed to some level of loud noise as a civilian and had not been seen for audiometric testing from 1971 to 2007 by the VA. When separating from the service with a whispered voice test and considering civilian occupation, history of infections and the time span of hearing loss over 35 years, it was the examiner's opinion that it was less likely than not that the Veteran's hearing loss was related to his military service, including the noise exposure therein. In a June 2011 addendum, the examiner noted that she had reviewed the claims file and that her opinion concerning the hearing loss had not changed. The Veteran clearly has a current hearing loss disability as shown by the audiological findings of record. Additionally, it is clear that he had noise exposure during service, as he served as a machine gunner. However, the evidence does not show a nexus between the current hearing loss and the in-service noise exposure. To the contrary, the VA audiologist, in her January 2009 and May/June 2011 opinions, specifically found that the Veteran's current hearing loss was less likely than not related to noise exposure in service. The examiner supported this opinion with a sufficient rationale (i.e. that hearing loss was not affirmatively shown at separation from service; that it was not subsequently documented for approximately 35 years (i.e. 2007) and that the Veteran had an intervening history of civilian noise exposure and ear infections. There is no medical opinion to the contrary (i.e. an opinion tending to indicate that the current hearing loss is related to noise exposure in service). The Veteran has alleged that he first noticed hearing loss right after separating from service and that he continued to experience it up until the present. Sensorineural hearing loss is a chronic condition as set forth in 38 C.F.R. § 3.303(a). Therefore, the theory of continuity of symptomatology is applicable in this case. 38 C.F.R. § 3.303(a),(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board notes, however, that the Veteran has stated that he had had ear infections over the past 35 years and that he had received medical treatment for them (i.e. medications); the VA examiner indicated that this was a potential cause of his hearing loss. He has not reported that he received a hearing evaluation prior to the VA evaluation in 2007, nor has he reported that he was referred for any such evaluation prior to this date. Additionally, the Veteran's wife provided only vague testimony that the Veteran's hearing loss had been going on "for years" and that she had asked him in the past to go get his ears checked. However, she did not testify that the Veteran started having hearing problems right after service, nor did she testify that he had had hearing problems for as long as she had been married to him (since June 1971). Thus, her testimony does not actually corroborate that the Veteran experienced hearing loss continuously since right after service. For all of these reasons, the Board does not find credible the Veteran's report of continuity of hearing loss symptomatology since service. Although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, as to the specific issue in this case, whether his current hearing loss is related to service, falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4. Consequently, given there is no competent medical evidence of any hearing loss until many, many years after service; given that there is no competent evidence of a nexus between the current hearing loss and military service; and given that the Veteran's report of continuity of hearing loss symptomatology since service is not credible, the weight of the evidence is against a finding of service connection on either a direct (or presumptive) basis. 38 C.F.R. § 3.303, 3.307, 3.309. The preponderance of the evidence is against this claim and it must be denied. ORDER Service connection for bilateral hearing loss is denied. Service connection for a skin rash is denied. Service connection for a left knee disability is denied. Service connection for a right knee disability is denied. Service connection for a back disability is denied. ____________________________________________ D. MARTZ AMES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs