Citation Nr: 1324975 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 03-00 093A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a back disability. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, and anxiety, due to in-service personal assaults. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from August 28, 1980 to December 18, 1980, with additional service in the United States Army Reserve from August 1980 to November 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. Jurisdiction rests with the RO in San Juan, the Commonwealth of Puerto Rico, from which the appeal was certified. Generally, the scope of a mental health disability claim includes any psychiatric disorder that may reasonably be encompassed by a Veteran's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). VA treatment records reveal multiple diagnoses of acquired psychiatric disorders, to include PTSD, depression, and anxiety. Accordingly, the Board has re-captioned the Veteran's claim as seen on the title page. Id. In November 2010, the Board reopened the Veteran's claims and remanded them for additional development. They have been returned to the Board for further appellate review. For the reasons discussed in greater detail below, the Board finds that there has been substantial compliance with the directives of the November 2010 remand, and therefore, an additional remand to comply with such directives is not required. See Stegall v. West, 11 Vet. App. 268 (1998). Multiple VA treatment records demonstrate reports that the Veteran was unemployable as the result of her PTSD. Therefore, the Board finds that the issue of entitlement to a TDIU has been raised by the record. However, as this issue has not been adjudicated by the RO, the Board does not have jurisdiction over it, and it is referred to the RO for appropriate action. FINDINGS OF FACT 1. The evidence of record does not establish that the Veteran experienced symptoms of chronic right knee pain during service or continuous symptoms of right knee pain since separation from service. 2. The Veteran's degenerative joint disease of the right knee did not manifest within one year of separation from service. 3. The probative, competent evidence of record does not demonstrate that a right knee disability is causally or etiologically related to service. 4. The evidence of record does not establish that the Veteran experienced symptoms of chronic back pain during service or continuous symptoms of back pain since separation from service. 5. The Veteran's degenerative disc disease of the spine did not manifest within one year of separation from service. 6. The probative, competent evidence of record does not demonstrate that a back disability is causally or etiologically related to service. 7. The competent medical evidence of record demonstrates that the Veteran is currently diagnosed with PTSD. 8. The competent evidence of record is at least in relative equipoise as to whether the Veteran's PTSD is related to in-service personal assaults. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee disability have not been met. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The criteria for service connection for a back disability have not been met. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 3. Resolving the benefit of the doubt in favor of the Veteran, the criteria for service connection for PTSD due to in-service personal assaults have been met. 38 U.S.C.A. §§ 1131, 1154, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304(f) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 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, 3.326(a) (2012). Proper notice from VA must inform the veteran of any information and 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 veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that VCAA notice as required by 38 U.S.C. § 5103(a) must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits. In addition, the notice requirements apply to all five elements of a service connection claim, including: (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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess/Hartman, 19 Vet. App. at 486. As the grant of service connection for PTSD due to in-service personal assaults represents a full grant of the benefits on appeal with respect to this issue, further discussion as to VA's duties to notify and assist are rendered moot. With respect to the remaining issues on appeal, the Board finds that all notification requirements have been met. The record shows that letters dated in January 2007 and March 2007 advised the Veteran of the foregoing elements of the notice requirements. See Quartuccio, 16 Vet. App. at 187; Dingess/Hartman, 19 Vet. App. at 486; 38 C.F.R. § 3.304(f). The Board notes that the requisite notice was not provided prior to the initial rating decision in May 2002. However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In any event, where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by re-adjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Following the issuance of the January 2007 and March 2007 letters, the Veteran's claims were re-adjudicated in Supplemental Statements of the Case dated in June 2010 and February 2013. For these reasons, the Board finds that the duty to notify the Veteran has been satisfied in this case. See Pelegrini, 18 Vet. App. at 120 (2004). Additionally, the Board finds the duty to assist the Veteran has been satisfied in this case. The RO has obtained the Veteran's service treatment records, private treatment records, Social Security Administration records, and identified private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In November 2010, the Board remanded the Veteran's claim for additional development. In particular, the Board instructed that the RO contact the Veteran and ask her to specify the periods she was in Fort Jackson, South Carolina, and Fort Benning, Georgia, and then attempt to obtain any records relating to treatment for the Veteran's knee and/or back conditions during those periods. In written statements in January 2011 and April 2011, the Veteran clarified that she had been treated at the Moncrief Army Community Hospital at Fort Jackson, South Carolina, but that she was never stationed at Fort Benning or Fort Gordon. Accordingly, the record shows the RO requested that the Moncrief Army Community Hospital provide any outpatient treatment records for the Veteran. A September 2011 report of general information shows that the Moncrief Army Community Hospital responded to the request, stating that there were no records for the Veteran at Fort Jackson as they would all be too old. All records would be located at the National Personnel Records Center (NPRC). A May 2012 record shows that the NPRC reported that no records could be located with respect to any treatment received by the Veteran at the Moncrief Army Community Hospital. In addition, the November 2010 Board remanded instructed that the RO afford the Veteran an appropriate VA examination to determine the nature and etiology of her right knee disability. Accordingly, the Veteran underwent VA examination in November 2011. However, because the Veteran's claims file was not available for review, the VA examiner stated that the requested opinion could not be provided. As a result, the Veteran underwent additional VA examination in January 2013. The record shows the January 2013 VA examiner reviewed the Veteran's claims file, to include her service treatment records, VA treatment records, and private treatment records, noted the reports of in-service injuries and treatment for the Veteran's right knee, completed a physical examination, and provided a complete opinion. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board finds the January 2013 VA examination and opinion to be sufficient and adequate for purposes of determining service connection. The Veteran was not specifically provided a VA examination to determine the etiology of her back disability. In disability compensation claims, VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the veteran qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for VA to make a decision on the claim. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, the competent evidence of record does not indicate that an event, injury, or disease occurred in service or that certain diseases, such as degenerative disc disease of the lumbar spine, manifested during an applicable presumptive period. The Veteran asserts that her current back disability is the result of an injury incurred when she attempted to pick up an M60 machine gun. However, service treatment records do not demonstrate an accident or injury was incurred in service, nor do the service treatment records demonstrate treatment for or chronicity of a back condition during service. In addition, although the Veteran asserts that she had sought treatment for her back pain since separation from service, the evidence of record does not demonstrate treatment for a back disability until 1992, approximately twelve years after her separation from active duty. In this respect, the Board also notes that presumptive periods do not apply to active duty for training or inactive duty training. Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). As such, the Veteran's contentions are the only evidence of record indicating a back injury was incurred during service. As will be discussed in greater detail below, the Board does not find that the Veteran's statements regarding an in-service injury and symptoms of back pain are credible evidence in support of the claim of entitlement to service connection for a back disability. Consequently, the Board finds that affording the Veteran a VA examination with respect to this issue was not warranted. McLendon, 20 Vet. App. at 83. For the reasons stated above, the Board finds the AMC substantially complied with the November 2011 remand directives. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). There is no indication in the record that any additional evidence relevant to the issue decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. All of the evidence in the Veteran's claims file has been thoroughly reviewed. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matter decided. The Veteran should not assume that pieces of evidence, not explicitly discussed, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1131. 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). 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). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. The term "active military, naval, or air service" includes active duty, any period of active duty for training during which the individual concerned was disabled or died from disease or injury incurred or aggravated in the line of duty, and any period of inactive duty training during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty. 38 U.S.C.A. § 101(24) (West 2002). Presumptive periods do not apply to active duty for training or inactive duty training. Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Right Knee Disability A September 1980 service treatment record demonstrates that the Veteran complained of a painful right knee and right foot for four days, with no injury and a sudden onset. The physician recorded that the pain seemed to be interior region of the knee bilaterally. The right knee had no swelling or discoloration but there was some warmth. The assessment was possible pulled muscle. An additional September 1980 service treatment record indicates the Veteran complained of right knee pain for four days and had tenderness to both ankles. She was referred to podiatry. In November 2011, the Veteran underwent VA examination in connection with her claim of entitlement to service connection for a right knee disability. The VA examiner noted that X-ray examination in April 2006 demonstrated degenerative joint disease. The Veteran reported that she had suffered right knee injury after a fall during military training. She was given an injection by a military doctor after the initial injury but denied any broken bones. The Veteran reported constant right knee pain since the initial injury and denied any other injury to her right knee. Because the Veteran's claims file was not available for review, the VA examiner stated an opinion could not be provided. As a result, the Veteran was afforded an additional VA examination in January 2013. The VA examiner reviewed the Veteran's claims file and performed an in-person examination of the Veteran. The VA examiner also noted the April 2006 diagnosis of degenerative joint disease of the right knee. The Veteran reported a history of a fall approximately two months after entering service. She stated that she tripped and fell onto her right knee and was treated for the condition at Fort Jackson. Physicians told her she had some trauma and swelling of the knee, and she reported that she was placed on a profile as the result. She stated that she had a history of chronic right knee pain since service. The Veteran did not know whether she had an orthopedic evaluation during service or since her discharge from service. The Veteran also reported falling into a pothole in 1993 and injuring her right knee again. She stated that she was not treated for the injury. X-ray examination revealed minimal degenerative change with stable appearance. The VA examiner recorded reviewing the claims file, the Veteran's medical records, her lay statements, and discussing the case with a Board certified rehabilitation medicine physician. In particular, the VA examiner noted the September 1980 service treatment records showing complaints of a painful right knee and treatment for a possible pulled muscle. The VA examiner reported that a review of literature revealed multiple risk factors for osteoarthritis in epidemiology studies, which included age, female sex, and obesity. The VA examiner opined that the Veteran's right knee condition did not have its onset during service and was not caused or etiologically related to a disease or injury incurred in service. The VA examiner found it significant that treatment records did not document any chronic right knee condition since the Veteran's separation from service and also noted the history of a fall with a right knee injury in April 2006. The VA examiner opined that the Veteran's current diagnosis was age and weight-related, as supported by medical literature. The VA examiner found there was no evidence of any chronic right knee condition in service and that when the Veteran was seen for a right knee complaint in service, the pain was more inferior to the knee and not in the knee joint itself. Further, there was no actual injury documented in service. Even if the Veteran's history was considered reliable, the VA examiner found the objective evidence did not support any chronic right knee condition since her military discharge in November 1986. First, the clinical evidence of record does not demonstrate that degenerative joint disease, or arthritis, manifested to a compensable degree within the year following active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As such, the Board finds the Veteran is not entitled to service connection for a right knee disability on a presumptive basis. X-ray examination in April 2006 and January 2013 revealed degenerative joint disease of the right knee, and as such, the Board finds the Veteran has established a current disability for the purpose of service connection. In addition, service treatment records dated in September 1980 demonstrate complaints of right knee pain during active duty. However, the service treatment records do not demonstrate that the Veteran experienced chronic symptoms of a right knee disability during service. In this respect, the Board acknowledges that in some circumstances, 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). In this respect, the Veteran has asserted that she has had right knee pain since service. The Veteran is competent to testify to matters within the realm of her personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that a lay witness is competent to testify to that which the witness has actually observed and is within the realm of his personal knowledge). However, while the Veteran's statements are competent evidence of events and symptomatology, the Board must also determine whether such evidence is credible. Id. In this respect, the evidence of record does not support the Veteran's statements regarding her symptoms during and since active duty. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). Although service treatment records document complaints of right knee pain in September 1980, the Veteran denied any specific injury on that occasion. In addition, the evidence does not demonstrate documentation of a profile after the reported injury. Therefore, the Board finds that the Veteran's statements as to her right knee symptoms during service are not supported by the evidence of record. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007) (holding that as a finder of fact, the Board, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing.) In addition, the evidence indicates that the Veteran did not seek treatment for right knee pain until April 2006, approximately 20 years following the Veteran's separation from service. As a result, the Board finds the Veteran has not established a continuity of symptomatology for the purpose of service connection. Here, the only competent medical opinion of record does not support a relationship between the Veteran's current right knee disability and active duty, to include any injury incurred therein. Here, the Board finds the opinion provided by the January 2013 VA examiner more probative than the Veteran's assertions. The VA examiner reviewed the Veteran's relevant medical history and her lay testimony concerning in-service and post-service symptoms. The VA examiner also provided an opinion as to the clinical findings and an adequate rationale for the opinions stated, relying on and citing to the records reviewed and pertinent medical literature. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The January 2013 VA examiner opined that the Veteran's right knee condition did not have its onset during service and was not caused or etiologically related to a disease or injury incurred in service. The VA examiner found it significant that treatment records did not document any chronic right knee condition since separation from service and also noted the recorded April 2006 right knee injury. The VA examiner also provided an alternative etiology for the Veteran's current diagnosis, finding that it was age and weight-related and stating that medical literature supported this determination. In addition, the VA examiner noted that when the Veteran was seen for right knee pain in service, the pain was more inferior to the knee and not in the knee joint itself. Furthermore, the VA examiner considered the Veteran's history as credible, but still opined that the objective evidence did not support any chronic right knee condition since separation from service. Again, the Veteran is competent to testify as to symptoms that are non-medical in nature; however, a layperson without medical training is not qualified to render a medical diagnosis or medical opinion concerning the etiology of degenerative joint disease of the right knee. See 38 C.F.R. § 3.159(a)(1). In certain unique instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Here, the Board finds that the relationship between the Veteran's current right knee disability and active duty is not something for which a layman is competent to provide an opinion. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). The evidence does not show that the Veteran possesses the requisite training or credentials needed to render a competent opinion as to the medical causation of degenerative joint disease of the right knee. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). As such, the lay opinions provided by the Veteran do not constitute competent medical evidence and lack probative value. Based on the foregoing, the Board finds that the preponderance of the evidence is against a grant of service connection for a right knee disability. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55-56. Back Disability The Veteran's service treatment records do not demonstrate complaints of, treatment for, or a diagnosis of a back disability, to include degenerative disc disease of the spine. In October 1992, the Veteran complained of excruciating low back pain with no known injury. The assessment was low back pain. X-ray examination revealed straightening of the lumbar spine with no fracture, dislocation or bone destruction. A November 1992 VA treatment record shows the Veteran reported low back pain for one year. In February 1993, the Veteran reported a history of low back pain for five years. An August 1993 VA treatment record shows the Veteran complained of having low back pain for five years. An October 1993 VA medical certificate indicates that the Veteran reported a history of low back pain since service. X-ray examination showed mild lumbar scoliosis, with convexity to the left side, which was thought to be positional in nature. A March 1994 VA treatment record shows a provisional diagnosis of rule out radiculopathy. The Veteran complained of low back pain radiating to the right lower extremity for eight years. On VA examination in May 1994, the Veteran reported injuring her back in 1980 when she bent down to pick up a machine gun. She reported receiving treatment and was told that she had a muscle injury. She also stated that she had seen doctors for her back since her separation from service. On examination, there were no postural abnormalities, no fixed deformity, and the musculature of the back showed a slight paravertebral muscle spasm. There was objective evidence of pain with all motions but no evidence of neurological involvement. The VA examiner diagnosed chronic low back spasm (fibromyositis). Records from the Social Security Administration indicate that the Veteran's disability benefits are based, at least in part, on her back disability. A November 2006 VA treatment record shows the Veteran reported that her back pain initially started in 1980 when she was lifting a heavy M60 machine gun during service. She also reported multiple other injuries to her back over the years. First, the clinical evidence of record does not demonstrate that degenerative disc disease of the spine, or arthritis, manifested to a compensable degree within the year following active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As such, the Board finds the Veteran is not entitled to service connection for a back disability on a presumptive basis. During the pendency of the appeal, however, VA treatment records demonstrate multiple diagnoses of a back disability, to include degenerative disc disease of the spine, degenerative changes at the L5-S1 disc level, a left foraminal herniated nucleus pulposes at the L3-4 disc region, and central and right-sided HNP at the L4-5 region. As such, the Board finds the Veteran has established a current disability for the purpose of service connection. With respect to an in-service injury, service treatment records do not demonstrate complaints of, treatment for, or a diagnosis of a back disability. Again, the Veteran is competent to provide evidence regarding an in-service back injury and symptoms of back pain because they address matters within the realm of her personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, while the Veteran's statements are competent evidence of events and symptomatology, the Board must also determine whether such evidence is credible. Id. In this respect, the Board finds it significant that while the Veteran's service treatment records do not demonstrate complaints of a back injury or back pain, they do reveal that she sought treatment for other injuries. Specifically, the Veteran sought treatment for right knee pain and ankle pain. Accordingly, the Board finds that the lack of evidence of complaints of and treatment for back pain in the service treatment records weighs against the Veteran's claim. Additionally, the Veteran asserted that as a result of her back pain, she was taken to the emergency room. Although there is documentation of an emergency room visit during service, the record demonstrates that the Veteran only complained of right knee and right ankle pain at that time. Furthermore, the Veteran's statements regarding the onset and duration of her back pain are not consistent throughout the record. See Caluza, 7 Vet. App. at 511 (noting that credibility may be impeached by a showing of inconsistent statements or consistency with other evidence), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In October 1992, the Veteran denied any known injury to her back, and in November 1992, she reported having had back pain for approximately one year. In February 1993 and August 1993 the Veteran reported a history of low back pain for five years; however, in October 1993 she reported a history of low back pain since service. In this respect, service personnel records show the Veteran was separated from Reserve service in 1986. In May 1994, the Veteran reported specifically injuring her back in 1980 when she bent down to pick up a machine gun. Furthermore, the first post-service medical evidence of record does not reveal treatment for a back disability until 1992, approximately six years after separation from service and twelve years following the reported injury. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of his low back condition). Therefore, the Board finds that the Veteran's statements as to the onset of back pain are not supported by the evidence of record. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007) (holding that as a finder of fact, the Board, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing.) Consequently, the Board does not find that the Veteran's statements regarding an in-service injury and symptoms of back pain are credible evidence in support of her claim, and as a result, the Board finds the Veteran has not established a continuity of symptomatology for the purpose of service connection. To the extent that the Veteran contends that her current back disability was caused by active service, the Board finds that these statements as to medical causation are not competent evidence to establish service connection for a low back disability. It is well established that a layperson without medical training is not qualified to render a medical opinion regarding the etiology of disabilities and diseases such as degenerative disc disease of the spine. See 38 C.F.R. § 3.159(a)(1). In certain unique instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, the evidence does not show that the Veteran possesses the requisite training or credentials needed to render a competent opinion as to medical causation of degenerative disc disease of the spine. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Here, the Board finds that the relationship between degenerative disc disease of the spine and an in-service injury is not something for which a layman is competent to provide an opinion. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). As such, the Veteran's lay opinion does not constitute competent medical evidence and lacks probative value. Additionally, the Board may not base a decision on its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). There is no post-service evidence of record beyond her personal assertions that relates the back disability to service. Based on the foregoing, the Board finds that the preponderance of the evidence is against a grant of service connection for a back disability. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal, and service connection must be denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55-56 (1990). PTSD due to in-service personal assaults In a May 2007 detailed stressor statement, the Veteran contends that she was sexually assaulted by her male superiors on three separate occasions during boot camp training. The Veteran asserts that she suffers from PTSD and other psychiatric disorders as the result of these incidents. The Veteran also provides the names and titles of the officers who initiated the sexual assaults, the time during which she was assaulted, and where she was stationed at the time of these incidents. The Veteran indicates that she did not report these incidents for fear of retaliation and the ruin of her military career. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and an in-service stressor. 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). 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). In addition, there are special evidentiary procedures for PTSD claims based on personal assault. Patton v. West, 12 Vet. App. 272, 278 (1999). In personal assault cases, more particularized requirements are established regarding the development of alternative sources of information as service records may be devoid of evidence because many victims of personal assault, especially sexual assault and domestic violence, do not file official reports either with military or civilian authorities. Specifically, evidence from sources other than the Veteran's service records may corroborate the Veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a PTSD claim that is based on an in-service personal assault without first advising the Veteran that evidence from sources other than the Veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing the Veteran the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. 38 C.F.R. § 3.304(f). Service personnel records indicate the Veteran was promoted in September 1982. Service personnel records also show the Veteran had multiple unexcused absences in June 1984. The Veteran failed to attend annual training from July 7, 1984 to July 21, 1984. In August 1984, she was reassigned for unsatisfactory participation and reduced twice in grade of rank. Service treatment records do not demonstrate complaints of, treatment for, or a diagnosis of an acquired psychiatric disorder. In addition, service treatment records do not include documentation pertaining to any sexual assault or treatment by a rape crisis center, mental health counseling center, hospital, or physician. In addition, the evidence does not demonstrate any in-service pregnancy tests or tests for sexually transmitted diseases. There is also no indication in the record that the alleged assaults in service were contemporaneously reported to any source that would have reduced the account to writing. In fact, the Veteran has stated on multiple occasions that she did not inform anyone of the assaults for quite some time after her separation from service. VA treatment records throughout the pendency of the appeal report that the Veteran had PTSD secondary to military sexual trauma. In May 1994, the Veteran underwent an initial VA evaluation in connection with her PTSD claim. The Veteran reported that she had many bad experiences of being sexually harassed and felt as though she would have been thrown out of the service if she did not do what they said. She described one incident when a lieutenant grabbed her in the woods and tried to kiss her and fondle her. She denied remembering any childhood abuse. The Veteran reported that approximately six months after separation from service she saw a private psychiatrist. After psychological examination, the VA examiner diagnosed generalized anxiety disorder and PTSD. The VA examiner found that the Veteran had both a generalized anxiety disorder and PTSD since her service, with each relating to and aggravating the other. Her psychiatric incapacity was described as moderate to severe. A November 2005 VA psychiatry outpatient note shows the Veteran had been seen for PTSD since May 2004. The VA physician stated that he had reviewed her records and met with the Veteran to review her history. The Veteran reported that she was raped when she was 10. In addition, she stated that on two different occasions in service she was assaulted by two different men. She stated that she was afraid to report the incidents as the men had threatened her with consequences. The VA physician opined that he very strongly believed that the Veteran had a service-connected disability. He stated that it was the intrusive thoughts of the military sexual trauma that caused her high level of anxiety rather than any memories of childhood sexual abuse. The VA examiner found that the Veteran had severe PTSD secondary to her military sexual trauma and that even if the childhood trauma had predisposed her to the military sexual trauma PTSD, at the very least the military sexual trauma would have been an aggravating factor. An October 2006 VA treatment record demonstrates that the Veteran reported her drill sergeant sexually assaulted and harassed her during basic training at Fort Dix. She stated that her drill sergeant threatened to give her a "black discharge" if she reported him. The Veteran also reported that her master sergeant had made sexual advances and physically touched her. In addition, she reported another incident at Fort Jackson where she was jumped from behind and kissed and fondled by a male soldier. The Veteran stated that she did not report any of the incidents. In December 2011, the Veteran underwent VA examination in conjunction with her claim of entitlement to service connection for an acquired psychiatric disorder. The VA examiner diagnosed PTSD, chronic; panic disorder without agoraphobia; depressive disorder, not otherwise specified; and cannabis abuse, sustained full remission. The VA examiner reviewed the Veteran's claims file, to include the service treatment records, separation documents, and VA treatment records, and performed psychological testing. The VA examiner opined that all of the three in-service incidents described by the Veteran were adequate to support the diagnosis of PTSD. The VA examiner also opined that the Veteran's chronic PTSD and panic disorder without agoraphobia were as likely as not etiologically related to her military service. The VA examiner noted that the Veteran presented a complex clinical picture, with a childhood history of sexual abuse and three incidents of sexual assault while in the military. The VA examiner stated that research had shown that PTSD had a greater risk of developing when there was the presence of an interpersonal violence, such as rape or assault, and multiple traumas exponentially increased the risk of PTSD development. As such, there was a cumulative effect of many traumas. The VA examiner opined that while the three incidents of sexual assault in service were not reported at the time and did not appear to have been verified, the Veteran was able to provide a detailed account of each military sexual trauma. In addition, a review of the treatment records going back to 1995 indicated that she had consistently been treated for PTSD and panic disorder. The VA examiner also found that the Veteran appeared to have provided a credible account of military sexual trauma and therefore met the diagnostic criteria for PTSD. A friend of the Veteran, R. M., submitted a May 2012 written statement in support of the Veteran's claim. She reported that she had been friends with the Veteran for over 25 years and had witnessed the Veteran's struggles over the years as the result of the horrific betrayal that occurred during service. R. M. stated that when she first met the Veteran, she was a vibrant woman passionate about serving in the Army. R. M. reported that soon after the Veteran's enlistment, she had begun telling her horror stories in painstaking detail of the abuse she underwent at the hands of men with higher ranking positions. R. M. stated that the Veteran had been sexually harassed at least three different times by different officials during her training. She stated that drill sergeants and one master sergeant were involved and that the Veteran was forced, touched, kicked, and fondled by the men. R. M. reported that the Veteran was terrified and felt helpless to the abuse because of the physical and physiological trauma. R. M. asserted that the Veteran was never the same after the trauma. Because the RO noted that the December 2011 VA examiner had not commented upon the marker showing a reduction in rank close to four years after the reported assaults, the Veteran was provided an additional VA psychological examination in January 2013. The VA examiner provided current diagnoses of PTSD, chronic; panic disorder without agoraphobia; and depressive disorder, not otherwise specified. After reviewing the claims file and performing a psychological evaluation, the VA examiner opined that PTSD was less likely than not incurred in or caused by the claimed in-service event. The VA examiner reported that a number of issues related to military sexual trauma claims had been taken into consideration in formulating the opinion. The VA examiner stated that the previous VA examiners had based their examinations and opinions on the Veteran's self-reported history without access to the claims file. The VA examiner found that the marker identified by the RO appeared to have been secondary to her not attending her required drills while in the Reserves and stated that there were no markers of military sexual trauma identified in any of the Veteran's personnel records. The VA examiner reviewed the statement provided by the Veteran's friend but dismissed it because the information was not a firsthand account of someone who knew the Veteran at the time of the claimed military sexual trauma. The VA examiner opined that the Veteran was a questionable historian given the inconsistencies noted in the records throughout the years. These inconsistencies could be seen across both medical and mental health issues, and the VA examiner found the details related to the Veteran's military sexual trauma had changed over time. For example, written statements by the Veteran indicated the military sexual trauma occurred during her first two weeks of boot camp as opposed to the last three weeks. The order of the military sexual trauma incidents had also switched around over time. The VA examiner found that in this case there were no records that could be indicative of a marker associated with military sexual trauma. Those records that contained information indicating some possibility of a military sexual trauma marker were dismissed as being markers. Initially, the Board notes that the Veteran did not engage in combat with the enemy for purposes of 38 U.S.C.A. § 1154. Indeed, the reported stressors do not involve combat. Therefore, the combat rule regarding acceptance of lay or other evidence alone to establish the occurrence of an alleged stressor does not apply. Therefore, the record must contain service records or other corroborative evidence which corroborates the occurrence of the claimed in-service stressor. After reviewing all of the evidence set forth above, the Board finds the Veteran competent to report the in-service sexual assaults and finds her statements to be credible. While there are some differences in the descriptions of the incidents offered during the pendency of the appeal, the Board does not find the statements to be inconsistent. Rather, the Board accepts the Veteran's characterization of them as detailed descriptions of the same event. Given the circumstantial evidence of record corroborating the reported military sexual assaults, the Board finds that the in-service stressors identified by the Veteran have been verified. Here, the Board finds that the evidence of the Veteran's marijuana use following service and the other behavioral changes described by R. M. are of the nature normally considered under 38 C.F.R. § 3.304. The Veteran and her friends are competent to report such symptoms they personally experienced or observed and when they began. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995). The Board finds this to be sufficient credible supporting evidence of the claimed sexual assault stressors. In addition, the Board finds that the competent medical evidence of record is at least in equipoise as to whether the Veteran's currently diagnosed PTSD is related to her military service. Critically, the May 1994, November 2005, and December 2011 VA physicians provided positive opinions with respect to a nexus. The May 1994 VA examiner found that the Veteran had had both a generalized anxiety disorder and PTSD since her service. The November 2005 VA physician stated that he had reviewed the Veteran's records and met with the Veteran to review her history. The VA physician opined that he very strongly believed that the Veteran had a service-connected disability. He stated that it was the intrusive thoughts of the military sexual trauma that caused her high level of anxiety rather than any memories of childhood sexual abuse. Likewise, the December 2011 VA examiner opined that all of the three in-service incidents described by the Veteran were adequate to support the diagnosis of PTSD and that the Veteran's chronic PTSD and panic disorder without agoraphobia were as likely as not etiologically related to her military service. The VA examiner opined that while the three incidents of sexual assault in service were not reported at the time and did not appear to have been verified, the Veteran was able to provide a detailed, credible account of each military sexual trauma. In addition, a review of the treatment records going back to 1995 indicated that she had consistently been treated for PTSD and panic disorder. The December 2011 VA medical opinion was based upon an extensive interview of the Veteran, a thorough review of the claims folder including the Veteran's contentions and service records, and thoughtful analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). In addition, the Board finds it significant that the January 2013 VA examiner's negative opinion appears to be based, in part, on inaccurate facts. Specifically, the January 2013 VA examiner asserted that previous opinions of record were not based on a review of the Veteran's claims file; however, the record demonstrates that the November 2005 and November 2011 VA examiners reviewed the Veteran's claims file and considered all the evidence of record when providing the positive opinions. In addition, the January 2013 VA examiner dismissed R. M.'s statements because the information was not a firsthand account of someone who knew the Veteran at the time of the claimed military sexual trauma. However, R. M. asserted that in May 2012, she had known the Veteran for over 25 years, which reflects R. M. had known the Veteran prior to and during service. Here, the Board has no reason to doubt R. M.'s credibility and as described in greater detail below, she is competent to report her personal observations of the Veteran's behavior. The Board acknowledges that the "markers" in the service personnel records do not appear to verify the Veteran's reported in-service stressors. However, the Board does not find it significant that there is no other evidence among the Veteran's service personnel records, other than the statements presented by the Veteran and R. M., of specific behavior changes following the claimed assault. Here, the Veteran only served on active duty from August 28, 1980 to December 18, 1980, and there is no reason to expect that the Veteran would present with any significant behavior changes during the short periods of active duty for training and inactive duty for training. Finally, the Board finds the Veteran's testimony with respect to her in-service military sexual trauma and resulting symptoms to be competent and credible evidence in support of her appeal. In addition, the Board finds the statements present by R. M. to be competent and credible evidence in support of the Veteran's appeal. While lay persons are generally not competent to offer evidence which requires medical knowledge, such as opinions regarding medical causation or a diagnosis, they may provide competent testimony as to visible symptoms and manifestations of a disorder. The Veteran is competent to give evidence about what she experienced; i.e., that she has had flashbacks, nightmares, and intrusive thoughts with respect to the stressors, and R. M. is competent to describe those visible manifestations of the Veteran's symptoms. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (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); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). Here, the Board finds nothing in the record that would refute the competency and credibility of the Veteran or R. M. with respect to her symptoms since separation from active duty service. Therefore, resolving the benefit of the doubt in favor of the Veteran, the Board finds that the Veteran's PTSD is related to military sexual trauma. Accordingly, service connection for PTSD due to in-service personal assaults is warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a back disability is denied. Entitlement to service connection for PTSD due to in-service personal assaults is granted. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs