Citation Nr: 1324360 Decision Date: 07/31/13 Archive Date: 08/07/13 DOCKET NO. 07-30 579 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for a left ankle disability. 4. Entitlement to service connection for a right knee disability. 5. Entitlement to service connection for a left knee disability, to include as secondary to a right knee disability. 6. Entitlement to service connection for a left thumb disability. 7. Entitlement to service connection for a right thumb disability, to include as secondary to a left thumb disability. REPRESENTATION Appellant represented by: Virginia Girard-Brady, Esquire WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD F. Yankey, Counsel INTRODUCTION The Veteran served on active duty from July 1963 to July 1967. This case comes before the Board of Veterans' Appeals (Board) on appeal of a December 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In a November 2009 decision, the Board denied service connection for bilateral hearing loss, tinnitus, a left ankle disorder, a bilateral knee disorder, and a bilateral thumb disorder. The Veteran appealed the denial to the Court of Appeals for Veterans Claims (Court). By July 2010 Order, the Court vacated the portion of the Board's November 2009 decision which denied service connection for the above-noted claims, and remanded the matter to the Board for compliance with instructions contained in a Joint Motion for Partial Remand of the parties. The case was returned to the Board for further appellate action in April 2012, at which time, the Board again denied the Veteran's claims for service connection for bilateral hearing loss, tinnitus, a left ankle disorder, a bilateral knee disorder, and a bilateral thumb disorder. By January 2013 Order, the Court again vacated the portion of the Board's November 2009 decision which denied service connection for the above-noted claims, and remanded the matter to the Board for compliance with instructions contained in another Joint Motion for Partial Remand of the parties. The case has been returned to the Board for further appellate action The Veteran testified before the undersigned at an October 2009 Video Conference hearing. The hearing transcript is of record. The issue of entitlement to service connection for tinnitus is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Bilateral hearing loss was not present in service or for years thereafter, and is not etiologically related to service. 2. A left ankle disability was not present in service or for years thereafter, and is not etiologically related to service. 3. A right knee disability was not present in service or for years thereafter, and is not etiologically related to service. 4. Degenerative arthritis of the left knee was not present in service, was not manifested within one year of the Veteran's discharge from service, and is not etiologically related to service or a service-connected disability. 5. A left thumb disability was not present in service or for years thereafter, and is not etiologically related to service. 6. A right thumb disability was not present in service, and is not etiologically related to service or a service-connected disability. CONCLUSIONS OF LAW 1. Bilateral hearing loss was not incurred in or aggravated by active military service and service incurrence may not be presumed. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2012). 2. A left ankle disability was not incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 3. A right knee disability was not incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 4. Degenerative arthritis of the left knee was not incurred or aggravated during active duty, its incurrence or aggravation during such service may not be presumed, and it is not proximately due to or the result of service-connected disability. 38 U.S.C.A. § 1110, 1112, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 5. A left thumb disability was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110 (West 2002); 38 C.F.R. §§ 3.303 (2012). 6. A right thumb disability was not incurred or aggravated during active duty, and it is not proximately due to or the result of service-connected disability. 38 U.S.C.A. §§ 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her 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 & Supp. 2008); 38 C.F.R. § 3.159(b) (2011); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). The notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim, defined to include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that in September 2006, prior to the initial adjudication of the claims, the Veteran was provided with the notice required under § 5103. The Board notes that, even though the letter requested a response within 60 days, it also expressly notified the Veteran that he had one year to submit the requested information and/or evidence, in compliance with 38 U.S.C.A. § 5103(b) (evidence must be received by the Secretary within one year from the date notice is sent). The Veteran was given the specific notice required by Dingess v. Nicholson, 19 Vet. App. 473 (2006) in the December 2006 and a subsequently submitted September 2009 letter. The Board notes that all pertinent evidence has been obtained in this case and the Veteran has been given an appropriate VA examination for his bilateral hearing loss, left ankle, bilateral knee and bilateral thumb disabilities. Neither the Veteran nor his representative has identified any additional evidence that could be obtained to substantiate the denied claims. The Board is also unaware of any such evidence. The Board remanded the claim in March 2011, to afford the Veteran examinations for his bilateral hearing loss, left ankle, bilateral knee, and bilateral thumb disabilities. The Veteran was afforded VA examinations in May 2011. The examinations provided the information requested in the remand, with regard to the claims for bilateral hearing loss, a left ankle disability, bilateral knee disabilities, and bilateral thumb disabilities, and in that regard, are adequate for rating purposes. The remand instructions were thereby complied with. Stegall v. West, 11 Vet. App. 268 (1998). In sum, the Board concludes that any errors in the notice and the development of the claim by the originating agency were not prejudicial to the Veteran. Legal Criteria Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). 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 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498 (1995); Hickson v. West, 12 Vet. App. 247 (1999); 38 C.F.R. § 3.303 (2012). An alternative method of establishing incurrence or aggravation and a nexus to service is through a demonstration of continuity of symptomatology. 38 C.F.R. § 3.303(b) (2012); Barr v. Nicholson, 21 Vet. App. 303 (2007); Clyburn v. West, 12 Vet. App. 296 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was noted during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Hickson v. West, 12 Vet. App. 247 (1999); 38 C.F.R. § 3.303(b) (2012). The theory of continuity of symptomatology can be used only in cases involving those disabilities explicitly recognized as chronic. 38 C.F.R. § 3.309(a) (2012); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability or death benefits. 38 U.S.C.A. 1154(a) (West 2002); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d at 1337 (Fed. Cir. 2006). Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. Wilson v. Derwinski, 2 Vet. App. 16 (1991). Once evidence is determined to be competent, the Board must then determine whether that competent evidence is also credible. Competency is a legal concept determining whether testimony may be heard and considered, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Layno v. Brown, 6 Vet. App. 465 (1994) 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) (2012). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests arthritis to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service-connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2012). However, that does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection on a secondary basis may not be granted without medical evidence of a current disability and medical evidence of a nexus between the current disability and a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512-514 (1998). Impaired hearing is considered a disability when the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of those frequencies are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2012). Sensorineural hearing loss is subject to service connection based upon continuity of symptomatology as an organic disease of the nervous system. 38 C.F.R. § 3.309(a) (2012). Any other form of hearing loss, such as conductive hearing loss, is not subject to service connection based upon continuity of symptomatology. Accordingly, the Veteran's claims of continuity of symptomatology have been considered and addressed. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Furthermore, where hearing loss that is an organic disease of the nervous system manifested to a compensable degree within one year following separation from service, service connection shall be granted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309 (2012). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2010); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Bilateral Hearing Loss The Veteran contends that he has bilateral hearing loss related to noise exposure during active service. Service treatment records, including the May 1967 separation examination report, are negative for any evidence of hearing loss. Furthermore, in his Report of Medical History completed at that time, the Veteran indicated that he did not have a history of hearing loss. The Board has also considered the Veteran's statements concerning in-service noise exposure. In this regard, he has reported that his hearing problems and tinnitus began in service, as a result of exposure to jet engines and aircraft noise. See October 2009 Video Conference hearing transcript and May 2011 VA examination report. The Veteran's DD-214 shows that he had a military occupational specialty of administrative specialist. However, it also shows that he served in the Air Force from 1963 to 1967 and was assigned to the 9th Bombardment Wing of the Strategic Air Command (SAC). Internet research shows that the 9th Bombardment Wing supported the SAC's combat operations in Southeast Asia in the mid- and late-1960s and early 1970s, furnishing aircraft and crews to other organizations. In giving due consideration to the places, types, and circumstances of his service, noise exposure in service is conceded. 38 U.S.C.A. § 1154(a) (2012). In-service incurrence of injury is therefore met as to acoustic trauma. The Board also notes that there is no dispute that the Veteran is competent to report hearing loss symptoms he experiences because that requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). VA treatment records dated from July 2006 to February 2009 show that the Veteran was noted in March 2007 to have a history of hearing loss. VA and private audiological examinations conducted in June 2008, February 2010, and April 2010 reveal complaints of tinnitus and findings of significant bilateral sensorineural hearing loss. None of the post-service medical evidence of record suggests that the Veteran's diagnosed bilateral hearing loss was related to noise exposure during his active military service. In accordance with the Board's March 2011 remand, the Veteran was afforded a VA audiological examination in May 2011. The Veteran complained of hearing loss which he reported began during military service, when he was exposed to B-52 aircraft noise. An audiogram conducted at that time showed bilateral sensorineural hearing loss beginning at 1500 hertz on the right and at 5000 hertz on the left. The audiologist opined that the Veteran's current hearing loss was less likely as not related to military acoustic trauma. In rendering his opinion he noted that service medical records showed that hearing sensitivity was within normal limits at the time of the Veteran's discharge, and there is no evidence in the Veteran's medical history of hearing loss within one year of his discharge. The audiologist also noted that, according to the Institute of Medicine report on noise exposure in the military, noise induced hearing loss occurred soon after exposure rather than weeks, months, or years after exposure. The Veteran's report of a continuity of hearing loss since service is competent evidence of a continuity of symptomatology. However, he first reported that continuity years after service and only in connection with a claim for VA compensation. Furthermore, the first contemporaneous evidence of hearing loss in the record is from 2007 VA treatment records, 40 years after his discharge from active service. Furthermore, the May 2011 VA audiologist who examined the Veteran and reviewed the claims folder has opined that the Veteran's hearing loss is not related to service. There is no contrary medical opinion of record. The Board finds that the May 2011 VA opinion was based on a full review of the record. Furthermore, the examiner considered the Veteran's history of noise exposure and onset of hearing loss in service, with his reports of a continuity of symptomatology since that time. The opinion is complete and sufficient upon which to base a decision with respect to the Veteran's claim for service connection for bilateral hearing loss. Barr v. Nicholson, 21 Vet. App. 303 (2007). It would require medical expertise to say that the current hearing loss identified long after service, is the result of in-service noise exposure. The Veteran, as a layperson, is not qualified to render an opinion concerning the medical cause of his hearing loss. 38 C.F.R. § 3.159(a)(1),(2) (2012). The Board finds that the examiner's opinion is more persuasive than the Veteran's assertions of continuity of symptomatology. Accordingly, the Board concludes that the preponderance of the evidence is against this claim and service connection for bilateral hearing loss on a direct basis is not in order. The Board also notes that without clinical evidence of manifestation of hearing loss to a compensable degree within a year after discharge, presumptive service connection also is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Ankle Disability (Chronic Strain) A left ankle disability was not diagnosed until many years after service, and there is no competent evidence to establish that a left ankle disability is due to any event or incident of the Veteran's period of active duty. Service treatment records show that in March 1964, the Veteran was treated for a twisted left ankle. He was diagnosed with a left ankle strain, and an associated x-ray was negative. At the time of the Veteran's discharge examination in May 1967, there were no complaints or findings related to the left ankle, the lower extremities were evaluated as normal, and no left ankle disability was diagnosed. In an associated Report of Medical History, the Veteran indicated that he did not have a history of swollen or painful joints, arthritis or rheumatism, or foot trouble. VA treatment records show that in 2007, the Veteran was treated for multiple contusions and abrasions/knee wounds following a March 2007 motor vehicle accident (MVA), in which he was thrown off of his motorcycle. He complained of symptoms that included left ankle and left knee pain. However, he was not diagnosed with a left ankle disability at that time, and another report notes that he was "in otherwise excellent health." With regard to the years-long evidentiary gap in this case between active service and the earliest manifestations of a left ankle disability, the Board notes that a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board must consider all the evidence, including the availability of medical records, the nature and course of the disease or disability, the amount of time that elapsed since military service, and any other relevant facts in considering a claim for service connection. Id. cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000) (holding that the absence of medical records during combat conditions does not establish absence of disability and thus suggesting that the absence of medical evidence may establish the absence of disability in other circumstances). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). There is no other medical evidence of record, VA or private, which indicates that the Veteran has a left ankle disability related to his active military service. In this regard, in accordance with the Board's March 2011 remand, the Veteran was afforded a VA examination in May 2011. The examiner noted the Veteran's reports of a left ankle sprain in service, in 1964 and continued intermittent pain and swelling in the left ankle since that time. X-rays of the left ankle revealed old healed fracture deformities involving the distal third of the tibia and fibula. There was no evidence of acute fracture or dislocation. Vascular calcifications were noted within the posterior soft tissues. The examiner diagnosed a chronic strain of the left ankle. With regard to the etiology of the left ankle disability, the examiner noted that the Veteran was treated for a left ankle sprain in 1964 in the military with an Ace bandage and a cane, and that there was no evidence that the Veteran was treated any more for his left ankle during military service, or for another 20 years after his discharge. He also noted that the Veteran was not found to have a chronic left ankle disability in the military or after his discharge. Based on this evidence, the examiner opined that it is less likely than not that the Veteran's left ankle condition is related to his one-time treatment for a left ankle sprain in the military. The Veteran is competent to report the symptoms of his disability, and he has attributed his current left ankle disability to a left ankle injury in service. However, it would require medical expertise to say that the left ankle disability identified many years after service, had its onset during or as a result of service. The Veteran, as a layperson, is not qualified to render an opinion concerning the medical cause of his left ankle disability. 38 C.F.R. § 3.159(a)(1),(2) (2012); Jandreau, supra. The only medical opinion of record addressing the claimed relationship between the Veteran's claimed left ankle disability and service is negative. No competent medical opinion linking any left ankle disability to service has been presented. The VA examiner considered the Veteran's lay assertions in forming his medical opinion, but ultimately found that the Veteran's reported left ankle symptoms were not related to service. There is no medical opinion against that of the VA examiner of record. The opinion was based on an accurate history and supported by a rationale; it is thus, adequate. Thus, the medical evidence of record is only against the Veteran's claim, and the claim is denied. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. Bilateral Knee Disability (Chronic Strain Right Knee; Degenerative Arthritis, Left Knee) A left or right knee disability was not diagnosed until many years after service, and there is no competent evidence to establish that a left or right knee disability is due to any event or incident of the Veteran's period of active duty. Service treatment records show that in June 1967, the Veteran was noted to have sustained a medial collateral ligament strain, related to playing tennis. An associated x-ray was negative. Service treatment records are negative for any evidence of complaints, treatment or diagnosis related to the left knee. At the time of the Veteran's discharge examination in May 1967, there were no complaints or findings related to the left ankle, the lower extremities were evaluated as normal, and no right or left knee disability was diagnosed. In an associated Report of medical history, the Veteran indicated that he did not have a history of swollen or painful joints, arthritis or rheumatism, or a trick' or locked knee. The post-service medical evidence of record does not show that the Veteran has a current right or left knee disability related to his active military service. VA treatment records show that the Veteran sustained a right knee injury in a January 1986 MVA, which required surgery. As noted above, in March 2007, he was involved in another MVA, at which time he complained of symptoms that included left knee and left ankle pain, and he was diagnosed with a left knee meniscal tear the following month. There is no indication that he was diagnosed with a right knee disability following either accident. With regard to the years-long evidentiary gap in this case between active service and the earliest manifestations of a right or left knee disability, the Board notes that a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board must consider all the evidence, including the availability of medical records, the nature and course of the disease or disability, the amount of time that elapsed since military service, and any other relevant facts in considering a claim for service connection. Id. cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000) (holding that the absence of medical records during combat conditions does not establish absence of disability and thus suggesting that the absence of medical evidence may establish the absence of disability in other circumstances). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). There is no other medical evidence of record, VA or private, which indicates that the Veteran has a current right or left knee disability related to his active military service. In this regard, in accordance with the Board's March 2011 remand, the Veteran was afforded a VA examination in May 2011. The Veteran reported that he twisted his right knee in the military in 1967, while playing tennis. He also reported that he was seen in the clinic and was diagnosed with medial collateral ligament strain, secondary to tension in the right knee. The examiner noted that x-rays at that time were negative for any fracture, dislocation, or any other conditions. The Veteran complained of weakness, instability and pain in the right knee since his reported right knee injury in service. The Veteran also reported that following his military service, he worked as a field trainer, and was actively involved in sports. He also reported that he injured his right knee again in 1986 and that he underwent surgery for the injury. On physical examination, x-rays of the right knee demonstrated no evidence of acute fracture or dislocation, and the articular margins and spaces of the knee appeared maintained. There was mild sharpening of the tibial spines, and vascular calcifications were noted within the posterior soft tissues. The examiner diagnosed a chronic right knee strain, status post surgery. He noted that besides the treatment for a medial collateral ligament strain in the right knee in service, in 1967, with negative x-rays, there was no documented evidence of any other treatment for a right knee condition in the military, or within 10 years of his discharge from the military. He also noted the Veteran's report of a 1986 right knee surgery, secondary to an injury. Based on this evidence, the examiner opined that it is less likely than not that the Veteran's right knee condition is secondary to his one-time treatment for a right knee condition in the military, or that it was aggravated by the military. The Veteran does not contend and the evidence does not show that his current left knee degenerative arthritis was incurred during his active military duty. Rather, he contends that he developed left knee pain around 1968 (one year after his discharge), trying to compensate for his right knee condition. On VA examination in May 2011, the Veteran was diagnosed with degenerative arthritis of the left knee. However, the examiner opined that, as there were no reports and no evidence of any left knee injury in service, and no documentary evidence of any treatment for the left knee within 5 years of the Veteran's discharge from service, it is less likely than not that the Veteran's left knee disability was caused by, related to, or aggravated by conditions incurred during or aggravated by his active military service. There are no medical opinions against those of the VA examiner of record. The opinions were based on an accurate history and supported by a rationale; thus, they are adequate. The Board also notes that the presumption of service connection for chronic diseases diagnosed within one year following discharge from active duty is also not applicable to the claim for a left knee disability, because the evidence demonstrates that the Veteran's left knee degenerative arthritis was initially diagnosed several years after the Veteran's discharge from service. Finally, as stated above, service connection on a secondary basis may not be granted without medical evidence of a current disability and medical evidence of a nexus between the current disability and a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512-514 (1998). The Veteran has a current diagnosis of degenerative arthritis of the left knee. However, the Board notes that the Veteran has not been granted service connection for a right knee disability or any other disability. Without evidence of a nexus between his current left knee disability and a service-connected disability, service connection on a secondary basis must also be denied. The Veteran is competent to report the symptoms of his disabilities, and he has attributed his current right knee disability to a right knee injury in service, and his left knee disability to his right knee disability. However, it would require medical expertise to say that the right knee disability, identified many years after service, had its onset during or as a result of service, or that his left knee disability, also diagnosed many years after service, was caused or aggravated by his right knee disability. The Veteran, as a layperson, is not qualified to render an opinion concerning the medical cause of his right or left knee disabilities. 38 C.F.R. § 3.159(a)(1),(2) (2012); Jandreau, supra. The only medical opinions of record addressing the claimed relationship between the Veteran's right and left knee disabilities and service, and his left knee disability and right knee disability are negative. No competent medical opinion linking any right or left knee disabilities to service, or any left knee disability to the right knee disability, has been presented. The VA examiner considered the Veteran's lay assertions in forming his medical opinions, but ultimately found that the Veteran's reported right and left knee symptoms were not related to service, and that his left knee disability was not related to any service-connected disability. Thus, the medical evidence of record is only against the Veteran's claims, and the claims are denied. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. Bilateral Thumb Disability (Intermittent Strain) A left or right thumb disability was not diagnosed until many years after service, and there is no competent evidence to establish that a left or right thumb disability is due to any event or incident of the Veteran's period of active duty. Service treatment records show that in June 1965, the Veteran was treated for a sprained left thumb, which was treated with a splint. Service treatment records are negative for any evidence of complaints, treatment or diagnosis related to the right thumb. At the time of his discharge examination in May 1967, there were no complaints or findings related to the thumbs, the upper extremities were evaluated as normal, and no thumb disability was diagnosed. There is no post-service medical evidence of record showing that the Veteran has received treatment for his thumbs, and there is no other medical evidence of record, VA or private, which indicates that the Veteran has a thumb disability related to his active military service. In this regard, in accordance with the Board's March 2011 remand, the Veteran was afforded a VA examination in May 2011. The Veteran reported spraining his left thumb lifting weight in June 1965, during military service, and being treated with a splint. He reported that he injured his right thumb in 1968 (one year after discharge) trying to compensate for the left thumb while lifting. The Veteran also reported that in 2008, after service, he developed an abscess in the right thumb when a splinter went into the thumb while he was working with wood. He also reported that he had an irrigation and debridement of the right thumb abcess. X-rays of the right and left hands were normal, with no evidence of acute fracture or dislocation, and no acute abnormality in the surrounding soft tissues. The examiner diagnosed intermittent strain of the bilateral thumbs. The examiner noted that, besides the documented left thumb sprain in June 1965, in the military, there was no evidence of any other treatment for the left thumb during the Veteran's military service, and no evidence of treatment for the left thumb within 5 years of his discharge. Based on this information, he opined that the chronicity of the Veteran's left thumb condition was not established in the military or after his discharge from the military, and therefore, it is less likely than not that the Veteran's left thumb condition was incurred during, or aggravated by, the Veteran's active duty military service. With regard to the right thumb, the examiner noted that there was no evidence of treatment during military service, or within 10 years of his discharge from the military. He also noted that after his discharge from the military, the Veteran worked as a basketball coach, and was actively involved in sports that required tacking and wrestling and, such as tennis, softball, golf, and running, which caused strain in all joints. Based on this information, the examiner opined that it is less likely than not that the Veteran's thumb condition was incurred during, or aggravated by his military service. There are no medical opinions against those of the VA examiner of record. The opinions were based on an accurate history and supported by a rationale; thus, they are adequate. The Board also notes that, as stated above, service connection on a secondary basis may not be granted without medical evidence of a current disability and medical evidence of a nexus between the current disability and a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512-514 (1998). The Veteran has a current diagnosis of a right thumb disability. However, the Board notes that the Veteran has not been granted service connection for his left thumb disability or any other disability. Without evidence of a nexus between his current right thumb disability and a service-connected disability, service connection on a secondary basis must also be denied. The Veteran is competent to report the symptoms of his disabilities, and he has attributed his current left thumb disability to a left thumb injury in service, and his right thumb disability to his left thumb disability. However, it would require medical expertise to say that the right or left thumb disability, identified many years after service, had its onset during or as a result of service, or that his right thumb disability, also diagnosed many years after service, was caused or aggravated by his left thumb disability. The Veteran, as a layperson, is not qualified to render an opinion concerning the medical cause of his right or left thumb disabilities. 38 C.F.R. § 3.159(a)(1),(2) (2012); Jandreau, supra. The only medical opinions of record addressing the claimed relationship between the Veteran's right and left thumb disabilities and service, are negative. No competent medical opinion linking any right or left thumb disabilities to service, or any right thumb disability to the left thumb disability, has been presented. The VA examiner considered the Veteran's lay assertions in forming his medical opinions, but ultimately found that the Veteran's reported right and left thumb symptoms were not related to service. Thus, the medical evidence of record is only against the Veteran's claims, and the claims are denied. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claims, that doctrine is not applicable. ORDER Service connection for bilateral hearing loss is denied. Service connection for a left ankle disability is denied. Service connection for a right knee disability is denied. Service connection for degenerative arthritis of the left knee is denied. Service connection for a left thumb disability is denied. Service connection for a right thumb disability is denied. REMAND As noted above, the Veteran contends that his current tinnitus is related to noise exposure in service. It is not in dispute that the Veteran has current tinnitus. The question is whether the disability is related to service. The Veteran was afforded a VA audiological examination in May 2011, in response to his claim. The examiner opined that given the Veteran's normal hearing sensitivity at the time of his discharge, coupled with the lack of evidence in the service treatment records of documented tinnitus in the military, it is less likely than not that his complaints of tinnitus are related to military acoustic trauma. See May 2011 VA audiological examination report. The Board notes that service connection is possible for disabilities first identified after service. 38 C.F.R. § 3.303(d). The April 2011 examiner did not provide an opinion as to whether the tinnitus identified after service is related to a disease or injury in service. Accordingly, the Board finds that with regard to the etiology of the Veteran's currently demonstrated tinnitus, the April 2011 VA opinion is inadequate for evaluation purposes. 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, 311 (2007). As such, the Board finds that a remand for a new medical opinion as to the etiology of the Veteran's tinnitus is necessary. See 38 C.F.R. § 4.2 (2011). The appellant is advised that it is his responsibility to report for the examination and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158 and 3.655 (2011). Accordingly, the case is REMANDED for the following action: 1. Return the claims folder to the examiner who provided the May 2011 VA examination and opinion so that he may determine the etiology of any current tinnitus. The examiner should review the claims folder, and acknowledge such review in the examination report or in an addendum. The examiner should provide an opinion as to whether it is as likely as not (50 percent probability or more) that any current tinnitus is etiologically related, in whole or in part, to the Veteran's active service. The examiner is advised that the Veteran is competent to report in-service injuries and symptoms and that his report of history must be considered in formulating any opinions. A rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. If the examiner who provided the previous examination is unavailable, another medical professional should review the claims folder and provide the necessary opinion and rationale. An additional examination should be afforded if the new examiner determines that one is necessary. 3. If the benefit sought on appeal is not granted, the agency of original jurisdiction should issue a supplemental statement of the case. The case should be returned to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs