Citation Nr: 1327071 Decision Date: 08/23/13 Archive Date: 08/29/13 DOCKET NO. 08-16 334 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for left foot callus of the 5th metatarsal head. 3. Entitlement to service connection for chronic sinusitis. 4. Entitlement to service connection for a migraine headache disability. 5. Entitlement to service connection for a lumbosacral strain disability. 6. Entitlement to service connection for a an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 7. Entitlement to service connection for gastroesophageal reflux disease (GERD) with dyspepsia. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD David S. Nelson, Counsel INTRODUCTION The Veteran had active duty service from February 1971 to August 1971 and from November 1990 to May 1991. The Veteran had inter-current service in the Army National Guard, presumably with periods of active duty for training (ACDUTRA) and Inactive duty training (INACDUTRA). A National Guard Bureau (NGB) Form 22 indicated that the Veteran was honorably discharged in August 2004. This case comes before the Board of Veterans' Appeals (BVA or Board) from a May 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. This case was previously before the Board in April 2012 and was remanded for additional development. In November 2011 the Veteran testified during a hearing at the RO before the undersigned Veterans Law Judge. A transcript of that hearing is of record. FINDINGS OF FACT 1. The evidence of record does not show that the Veteran currently has a right knee disability related to her military service. 2. There has been no demonstration by competent clinical evidence, or credible lay evidence, that a left foot callus of the 5th metatarsal head was present in service or that there is a nexus or link between a left foot callus of the 5th metatarsal head and the Veteran's military service. 3. Clear and unmistakable evidence of record establishes that chronic sinusitis preexisted the Veteran's period of active duty service from November 1990 to May 1991 and was not aggravated by such service. 4. The Veteran has migraine headaches that as likely as not had its onset in service duty or is otherwise etiologically related thereto. 5. The evidence of record does not show that any low back disability was incurred in or the result of military service. 6. Competent clinical evidence of record establishes a current diagnosis of PTSD associated with an in-service stressor. 7. The evidence of record does not show that any that GERD was incurred in or the result of military service. CONCLUSIONS OF LAW 1. Service connection for a right knee disability is not warranted. 38 U.S.C.A. §§ 101(2), 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303 (2012). 2. Service connection for a left foot callus of the 5th metatarsal head disability is not warranted. 38 U.S.C.A. §§ 101(2), 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303 (2012). 3. Service connection for chronic sinusitis is not warranted. 38 U.S.C.A. §§ 101(24), 106, 1110, 1111, 1112, 1113, 1131, 1137, 1153, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304, 3.306 (2012). 4. Service connection for a migraine headache disability is warranted. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 5. Service connection for a lumbosacral strain disability is not warranted. 38 U.S.C.A. §§ 101(2), 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303 (2012). 6. The criteria for service connection for PTSD with depressive disorder has been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 7. Service connection for GERD with dyspepsia is not warranted. 38 U.S.C.A. §§ 101(2), 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Duty to Notify Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor her representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in January 2005 of the criteria for establishing service connection, the evidence required in this regard, and her and VA's respective duties for obtaining evidence. She also was notified in March 2006 of how VA determines disability ratings and effective dates if service connection is awarded. These letters accordingly addressed all notice elements and predated the initial adjudication by the AOJ/RO in May 2006. Duty to Assist The Veteran's service treatment records are associated with the claims file. Identified VA medical records are associated with the physical claims file and the Veteran's Virtual VA file. There are no outstanding records that have not otherwise been obtained. In July 2012 the Veteran underwent a VA examination that addresses the medical matters presented by this appeal. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA July 2012 opinions obtained in this case are more than adequate. The July 2012 VA examiner elicited information concerning the Veteran's military service and performed a contemporaneous physical examination. The opinion considered the pertinent evidence of record, the Veteran's lay history, included a specific reference to the Veteran's service treatment records, and provided a rationale for its conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). As the evidence does not establish that the Veteran suffered an injury, disease or event noted during military service related to a left foot callus of the 5th metatarsal head, the Board finds that affording the Veteran an examination for the purpose of obtaining an opinion concerning a possible relationship between a left foot callus of the 5th metatarsal head and her military service is not appropriate in this case. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). During the November 2011 Board hearing, to assist the Veteran, questions were asked to help direct the Veteran's testimony concerning the onset of her claimed disabilities. Further, questions were asked to ensure that the relevant evidence was associated with the claims file. These actions fulfilled the duties in Bryant v. Shinseki, 23 Vet. App. 488 (2010), and the Veteran has not asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) or identified any prejudice in the conduct of the hearing. As such, the Board finds that, consistent with Bryant, the Board complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claims based on the current record. The Board finds that there has been substantial compliance with its April 2012 remand instructions. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In particular, VA medical records available through the Compensation and Pension Records Interchange (CAPRI) were uploaded to the Veteran's electronic Virtual VA folder. Further, additional service personnel records have been associated with the claims file, and, as noted, the Veteran has undergone VA examinations that address the medical matters raised by this appeal. The Veteran has not referenced any other pertinent, obtainable evidence that remains outstanding. VA's duties to notify and assist are met, and the Board will address the merits of the claims. Applicable Laws-Service connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F. 3d 1362, 1366 (Fed. Cir. 2010). The term "veteran" is defined in 38 U.S.C.A. § 101(2) as a person who served in the active military, naval, or air service, and who was discharged or released under conditions other than dishonorable. Active military, naval, or air service includes active duty. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). It also includes any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty and any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. Id. An individual who has served on active duty is a Veteran while an individual who has served only on ACDUTRA and/or INACDUTRA must establish a service-connected disability in order to achieve Veteran status. Paulson v. Brown, 7 Vet. App. 466 (1995). Service connection for certain specified chronic diseases, such as arthritis, psychoses, and migraine headaches (as an organic disease of the nervous system) may be established on a presumptive basis by showing that such disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. Whether a layperson opinion as to a nexus or a diagnosis is competent evidence depends on the facts of the particular case. See Davidson v. Nicholson, 581 F.3d 1313 (Fed. Cir. 2009). One factor for consideration is the complexity of the question to be determined. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (providing an example in footnote 4 that a layperson would be competent to diagnose a simple condition such as a broken leg but not competent to diagnose a form of cancer). Another factor is whether the question can be answered by personal observation alone. See Layno v. Brown, 6 Vet. App. 465, 496 (1994) (explaining that a layperson is competent to report only that which he or she observed). VA is required to evaluate the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the veteran served, the veteran's military records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). The Board notes that although all the evidence has been reviewed, only the most salient and relevant evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). The Veteran's service treatment records for her period of active duty service from February 1971 to August 1971 do not contain any relevant findings, and will not be further discussed. In this regard, the Board notes that the Veteran has not asserted that any of the disabilities on appeal are related to her period of service from February 1971 to August 1971. Also of note is the fact that the Veteran was deployed to Saudi Arabia from January 14, 1991 to April 19, 1991. I. Right knee disability At the November 2011 Board hearing the Veteran stated that she had injured her right knee after falling out of a truck. She did not provide further testimony concerning her right knee. Service records indicate that the Veteran suffered a right knee injury when she fell out of a truck in the line of duty while serving with the Alabama Army National Guard. The Veteran was diagnosed with a first degree medial collateral ligament (MCL) strain. A February 22, 1993 consultation note indicated that the Veteran complained of tenderness over the medial femoral condoyle MCL insertion as well as retro-patella pain. A March 5, 1993 follow-up note indicated that the Veteran was making slow improvement but still had tenderness along the medial joint line and also had pain upon McMurray's testing. The examiner indicated that the Veteran might have had a small tear in the medial meniscus. A September 1995 annual medical certificate reflects that the Veteran noted right knee disability. A December 2007 VA examination noted right knee lateral tenderness with no objective right knee joint abnormality noted. At the July 2012 VA examination the Veteran complained of constant knee pain that would worsen with prolonged walking. The Veteran had right knee flexion to 85 degrees and extension to 0 degrees. While pain on movement was noted, there was no anterior, posterior, or medial-lateral instability, and no subluxation. X-rays revealed no abnormality. The diagnosis was MCL strain. The examiner noted that the Veteran's knee strain had been appropriately treated in service and that there was no medical evidence for chronic residuals from the in-service knee injury. The examiner indicated that a MCL strain does not last 25 years. The existence of a current disability is the cornerstone of a claim for VA disability compensation. In the absence of proof of a present disability there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The July 2012 VA examiner has identified no right knee disability other than right knee pain and has specifically stated that there are no chronic residuals from the 1993 in-service right knee injury. There are no other records showing the existence of a right knee disability during the duration of this appeal, including the December 2007 VA examination. It is important to note that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. Principi, 239 F. 3d 1356 (2001). As the evidence does not show that the Veteran has a current right knee disability, there is no basis upon which to grant service connection for this claim and it must be denied. While acknowledging that the Veteran has had some medical training, the Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to diagnose an orthopedic disability. As such, service connection for a right knee disability is not warranted. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence weighs against the claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). II. Left foot callus of the 5th metatarsal head The Veteran's service treatment records reveal that a left foot 5th metatarsal head disability was not noted in service. A February 2005 VA treatment record noted that the Veteran had calluses on the left foot 5th metatarsal head trimmed. A December 2007 VA examination of the feet did not reveal, other than hallux valgus, any abnormal findings of the feet. At the November 2011 Board hearing the Veteran stated that she had no problems with her feet prior to her deployment to Saudi Arabia. She stated that she was issued boots that were too small that would crush her feet when marching in the sand. She indicated that she was currently treating the condition by taking a razor blade and cutting it by herself. To the extent it can be argued that the Veteran has a current left foot callus disability, the service and post-service medical records do not show or contain any evidence suggesting a relationship between a left foot callus and the Veteran's service. Further, even assuming that the Veteran is competent to state that she has a left foot callus disability, and that she has had a left foot callus disability since 1991, the Board finds that such assertions lack credibility. Records such as a July 1997 annual medical certificate, a December 2002 private physician's letter discussing the Veteran's Army Reserve restrictions, and the December 2007 VA general medical examination did not note any left foot callus disability. These records are dated subsequent to her April 1991 redeployment from Saudi Arabia. Had she been having left foot problems as she claimed, the Board believes that she would have mentioned such when noting other medical problems. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (where there is a lack of notation of medical condition or symptoms where such notation would normally be expected, the Board may consider this as evidence that the condition or symptoms did not exist). A review of the evidence has revealed that a chronic left foot callus of the 5th metatarsal head disability did not have its onset during the Veteran's active duty service and was not caused by her active duty service. There is simply no competent or credible lay or medical evidence that the claimed disability is related to any qualifying period of military service. As the preponderance of evidence is unfavorable to the claim, the Board must deny the appeal as to entitlement to service connection for a left foot callus of the 5th metatarsal head disability. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. III. Sinusitis The Veteran asserts that she developed sinusitis in 1985 after having completed a term of service in Germany. At her November 2011 Board hearing she stated that it was raining and cold at that time in Germany and she had to go to sick call as "her head was not right." The Veteran states that she was informed that she had a sinus problem and was given an antibiotic. The Veteran stated that she had not previously had a sinus infection but had had them ever since. A review of the Veteran's service treatment records reveals that the first mention of sinus problems is contained on a January 1990 Report of Medical History, wherein the Veteran indicated "yes" to the question of whether she had or ever had sinusitis. No further details were provided. A January 1990 service examination report indicates that the Veteran's sinuses were clinically evaluated as normal. A December 1990 service treatment record noted that the Veteran complained of sinus problems that also affected her ears. The assessment was rule out sinusitis. An April 1991 service treatment record noted that the Veteran complained of sinus headaches. June 2001 and April 2004 private records and an October 2004 and October 2007 VA record noted complaints related to sinusitis. In a July 2005 statement the Veteran stated that she first developed sinus problems in 1985 in Germany during "REFORGER 1985." She states she went to sick call at that time. She stated that her sinuses worsened when sent to Germany again in 2001. A December 2007 general medical examination indicated that there had been no episodes of sinusitis the prior year. At the July 2012 VA examination the Veteran indicated that her symptoms of sinusitis included headaches, pain, and tenderness of affected sinus. There were no incapacitating episodes of sinusitis requiring prolonged use of antibiotics treatment in the past 12 months or non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting in the past 12 months. The examiner stated that the Veteran's sinusitis was less likely as not aggravated by service. It was noted that service treatment records only indicated sinusitis that did not reach the level of aggravation beyond natural progression. The examiner stated that flare-ups are common during the season and also due to infections and there was no evidence for any significant event occurring in the service such that aggravation occurred. It was further noted that it was not until the 2000s that there was evidence of an increase in pattern of sinus symptoms, some 10 years after military service. VA law provides that a veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where clear and unmistakable evidence establishes that an injury or disease existed prior to service and was not aggravated by service. See 38 U.S.C.A. § 1111. The presumption of soundness attaches only where there has been an induction examination during which the disability about which the veteran later complains was not detected. The regulations provide expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," and that "[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions." 38 C.F.R. § 3.304(b). The law further provides that, if a preexisting disorder is noted upon entry into service, the veteran cannot bring a claim for service incurrence for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. In that case, the provisions of 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306 apply, and the burden falls on the veteran to establish aggravation. Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If a presumption of aggravation under section 1153 arises, due to an increase in a disability in service, the burden shifts to the government to show a lack of aggravation by establishing "that the increase in disability is due to the natural progress of the disease." 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306; Jensen, 19 F.3d at 1417; Wagner v. Principi, 370 F. 3d 1089, 1096 (Fed. Cir. 2004). While the Veteran has indicated that she developed sinusitis in 1985, the available evidence of record does not reveal any mention of sinusitis until December 1990. As for the Veteran's period of active duty service from November 21, 1990, to May 12, 1991, the Veteran did not undergo an entrance examination prior to the start of that period of service. As such, a sinus disability was not noted (per Crowe v. Brown, 7 Vet. App. 238 (1994)) at the time of examination for entrance or enrollment into the Veteran's period of active duty service from November 21, 1990 to May 12, 1991. Accordingly, the presumption of soundness as to a sinus disability attaches. While a sinus disability was not noted at the time of examination for entrance into the Veteran's period of active service from November 21, 1990 to May 12, 1991, the Veteran indicated on a Report of Medical History shortly thereafter in January 1990 "yes" to the question of whether she had or ever had sinusitis. The Veteran has consistently maintained that she had a sinus disability prior to her period of service beginning in November 1990, and the July 2012 VA examiner did not dispute that assertion. As such, the record clearly and unmistakably establishes that the Veteran had a sinus disability prior to the beginning of her period of active service beginning in November 1990. Additionally, clear and unmistakable evidence establishes that the pre-existing sinus disability did not undergo any increase in service. While service treatment records reveal that the Veteran complained of sinus problems in December 1990 and April 1991, as noted by the July 2012 VA examiner, such flare-ups are common and there was no evidence for any significant event occurring in the service such that aggravation occurred. The examiner also noted, and the medical evidence reveals, that it was not until the 2000s that there was evidence of an increase in pattern of sinus symptoms, some 10 years after military service. In view of the foregoing, the Board finds that competent evidence of record clearly and unmistakably shows that the Veteran had a pre-existing sinus disability prior to service and that such was not aggravated by service. 38 U.S.C.A. § 1111. As such, the presumption of soundness as to a sinus disability is rebutted, and the Board must consider whether the pre-existing sinus disability was aggravated in service pursuant to 38 U.S.C.A. § 1153. As explained above, there has been no demonstration of chronic increase in the sinus disability during service. In this regard, while the Veteran has stated that her sinus disability was aggravated when she was sent to Germany in 2001, there is no evidence in the available medical records, service or otherwise, showing any complaints of sinus symptoms in connection with such service. Based on the foregoing, service connection for sinusitis is not warranted, and there is no reasonable doubt to be resolved as to this issue. IV. Migraine headaches disability At the November 2011 Board hearing the Veteran stated that her headaches disability had begun when she developed food poisoning from a MRE while she was serving in Saudi Arabia. She stated that she was not treated for headaches until following her discharge from service. An April 1991 service treatment record noted treatment for sinus headaches. The remaining service treatment records do not reveal complaints or treatment for headaches. A September 1995 annual medical certificate reflects that the Veteran noted migraine headaches. An October 1999 private record noted that the Veteran had headaches that had begun four days prior. A February 2002 private record noted that the Veteran complained of headaches that had begun the prior night. It was noted that the Veteran had vomited three times. September 2004, October 2004 VA, and December 2004 treatment records noted that the Veteran stated that she had headaches ever since serving in Saudi Arabia in 1991. She reported constant headaches since 1991 that had worsened since 2000. She could not recall any trauma or event that had triggered her headaches while serving in Saudi Arabia. The pain from headaches could be so severe that she would want to "blow her brain out." The diagnosis was migraine headaches. An April 2005 VA record reflects that the Veteran had had headache pain for years. An October 2004 physical profile (DA Form 3349) reflects that the Veteran complained of migraine headaches. A March 2006 statement from Master Sergeant (MSG) DH, Retired (RET) indicated that in May 1991 the Veteran had complained to DH of having headaches. DH indicated that the Veteran had not complained to her of having headaches prior to her deployment to Saudi Arabia. VA records dated in 2007 reflect continued treatment for severe migraine headaches. At a July 2012 VA examination the Veteran stated that once a month she had headache pain that would typically last more than 2 days. The Veteran's headaches impacted her ability to work. The examiner stated that the Veteran's migraine headaches were less likely as not related to, or caused by the Veteran's military service. The examiner stated that there was no medical evidence for any chronic migraines in service. The only headaches that were treated in service were associated with an infection (sinus) or other causes. The examiner did not see any treatment or a diagnosis for a primary headache condition until the 2000s. The Board finds that the Veteran has consistently maintained that she began to develop headaches in service while serving in Saudi Arabia. While the Veteran has acknowledged that she did not seek treatment at that time, the Board finds her assertions of having headaches during service to be credible. Such assertions are essentially substantiated by the comments from Master Sergeant DH and equate to a showing of continuity of symptomatology since service as is required to support a finding of chronicity. Resolving doubt in the Veteran's favor, the Board finds that the record establishes that service connection for migraine headaches is warranted. V. Lumbosacral strain disability. At her November 2011 Board hearing the Veteran stated that she had injured her back after falling out of a truck while serving in Kentucky. She stated that she went to sick call and was given muscle relaxers. The Veteran clarified that the incident had happened after returning home from Saudi Arabia. An October 1983 service treatment record indicated that the Veteran was treated for a lumbar strain. A March 1985 service treatment record indicates that the Veteran had back spasms that were incurred in the line of duty. A January 1990 service examination report indicates that the Veteran's spine was clinically evaluated as normal; the Veteran specifically denied that she had recurrent back pain on the corresponding Medical History Report. A September 1995 annual medical certificate reflects that the Veteran made no complaints related to a low back disability. A December 2002 private physician's letter discussing the Veteran's Army Reserve restrictions did not note any low back disability. A December 2007 VA examination noted no low back disability. At the July 2012 VA examination the examiner stated that the Veteran's low back disability was less likely as not related to the Veteran's military service. The examiner indicated that the Veteran's service treatment records showed only a self limited episode of lumbar spine sprain based on the nature of the injury and the findings on examination at that time. There was no medical evidence for chronic residuals. It was noted that the service treatment records and subsequent medical data did not show any chronic residuals. The examiner stated that a lumbar sprain does not last for over 25 years. The X-rays for the lumbosacral spine were normal, which was significant and unexpected considering the Veteran's age. Even assuming the presence of a current lumbar spine disability, the Veteran's service treatment records do not tend to show that the Veteran had a chronic low back disability that had its onset during service. While complaints of back problems were made on a couple occasions in the 1980s, there appears to be no other low back complaints made during her subsequent service. As various service treatment records dated subsequent to March 1985 do document, however, the Veteran seeking treatment for other health issues, it is reasonable to assume that the Veteran would have sought out treatment for her low back had the complaints of pain or difficulties persisted. As for post-service medical evidence, the private and VA records do not show or contain any evidence suggesting a relationship between any low back disability and the Veteran's military service. Significantly, the July 2012 VA examiner specifically stated that the Veteran's low back disability was not related to the Veteran's military service. The July 2012 VA physician's opinion is evidence against the Veteran's claim and the Board affords the July 2012 VA examiner's opinion considerable probative value because the examiner provided a compelling and logical rationale for the ultimate conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (explaining that most of the value of a medical opinion comes from its reasoning). Further lending weight to the July VA examiner's opinion is the fact that he made specific references to findings from clinical records associated with the claims file. In essence, the Veteran in this case is relying on her own reports of in-service back symptoms as a basis for awarding compensation benefits. To the extent that she argues that an in-service injury caused her current low back disability, the Board finds her statements are not competent evidence. Taking the aforementioned Davidson, Jandreau, and Layno together leads the Board to the conclusion that the complexity of the question, such as whether asserted in-service sprains or joint pain results into a current low back disability can not be determined by direct observation and is not a simple question. While acknowledging that the veteran has some medical training, nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating orthopedic disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Her opinion in this regard is not competent evidence and is not favorable to her claim. As for continuity of symptomatology since service, the Board notes that it appears that the Veteran has not been diagnosed with arthritis of the low back. At any rate, had she been experiencing such pain since service, it would have been logical for her to make such complaints at that time and thereafter. This is especially apparent in that the multiple entries dated in February 1993 to May 1993 concerning the Veteran's right knee make no mention of any back problems, even though the Veteran has stated that she had injured her back at that time. A review of the evidence has revealed that a low back disability did not have onset during her active service and was not caused by her active service. As the preponderance of evidence is unfavorable to the claim, the Board must deny the issue of entitlement to service connection for low back disability. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. VI. Acquired psychiatric disorder, to include PTSD At the November 2011 Board hearing the Veteran stated that she was currently being treated by VA for depression and PTSD and was taking medications for those disabilities. She stated that there had been SCUD missile explosions near the barracks where she lived while stationed in Saudi Arabia. She indicated that she had been too emotionally upset to respond appropriately to questions she had been asked during a May 2011 VA PTSD examination. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (2012); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2012); see Cohen v. Brown, 10 Vet. App. 128 (1997). For VA compensation purposes, 38 C.F.R. § 4.125 requires that all mental disorder diagnoses must conform to the Fourth Edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). A September 1985 service examination report indicates that the Veteran's psychiatric system was clinically evaluated as normal. On the corresponding Medical History Report the Veteran indicated yes to the question of whether she had or ever had depression or excessive worry and nervous trouble of any sort; it was noted that the Veteran was controlling anxiety (apparently related to her divorce) extremely well. A January 1990 service examination report indicates that the Veteran's psychiatric system was clinically evaluated as normal; the Veteran denied any depression or excessive worry on the corresponding Medical History Report. She also noted that she had anorexia in 1978. In May 1992 the Veteran was awarded the Army Commendation Medal (ARCOM) for her service from November 1990 to April 1991. The citation noted that the Veteran had performed duties as a medical specialist in a highly commendable manner under very stressful conditions. A December 8, 2004 VA mental health treatment record reveals that the Veteran stated that she had been feeling depressed ever since returning from Saudi Arabia. She was having dreams and intrusive thoughts about events that had happened in Saudi Arabia that she still found hard to discuss. She stated that she had sought mental health treatment from VA after returning from Saudi Arabia but had been "turned away." The physician noted that the session lasted one hour. The diagnoses listed under DIAGNOSTIC IMPRESSION ACCORDING TO DSM IV" included PTSD and depressive disorder. A December 30, 2004 VA psychiatric treatment record noted that the Veteran had indicated that she had been close to or witnessed SCUD missile attacks during her service in the Persian Gulf. She reported frequent intrusive thoughts and nightmares related to her military service in the Gulf. The physician's assessment included PTSD and depressive disorder. A January 11, 2005 VA mental health record indicates that the Veteran was administered the Millon Clinical Multiaxial Inventory 3rd Edition (MCMI3) psychology assessment that revealed clinical features that included PTSD. A January 25, 2005 VA treatment record noted that the Veteran continued to receive treatment for PTSD and a depressive disorder. A March 2006 statement from Master Sergeant DH indicated that in May 1991 the Veteran had complained to DH of feeling depressed. DH indicated that the Veteran had not complained to her of having any illness prior to her deployment to Saudi Arabia. DH indicated that the Veteran had complained to her that she had irritability from recurrences of bad dreams related to her service in Saudi Arabia. At a May 2011 VA PTSD examination the Veteran indicated that she had witnessed a SCUD missile "coming." that had produced an intense fear and a feeling of hopelessness. The Veteran also related multiple instances of sexual assault and harassment that she asserted had happened during her various periods of military service. The examiner stated that the Veteran had met the DSM-IV stressor criterion for PTSD, and again noted the Veteran's SCUD missile and sexual assault incidents. The examiner stated that due to the Veteran's vague and inconsistent reports during his examination he was unable to provide an Axis I diagnosis, although the examiner did note that it was clear that the Veteran had a "diagnosable mental illness." The examiner also stated that it was possible that the Veteran had PTSD due to sexual assault but was unable to resolve that issue with the information presented by the Veteran. At a July 2012 VA examination the Veteran appeared confused and asked frequently why she was participating in the examination. The examiner explained several times the purpose of the examination. According to the examiner, the Veteran could not recall when she last worked, when she got out of the reserves, the names of any medications or the ages of her children. However, the Veteran was fully oriented and remembered that the examiner was 17 minutes late for the appointment. After an hour of trying to conduct the examination, it became quite evident to the examiner that the Veteran was not going to be able to complete the examination. The examiner also indicated that as the Veteran was not going to be able to provide additional information that was needed to answer the requested medical opinion, the examination was terminated. A June 2012 RO PTSD Stressor Review Checklist indicated that the Veteran had alleged a fear of incoming SCUD missiles during service. It was noted that the Veteran's stressor was consistent with the places, types, and circumstances of service as her personnel records indicated that the Veteran had received the Kuwait Liberation Medal during Operation Desert Shield/Storm from November 21, 1990 to May 12, 1991. A VA physician has indicated that the Veteran has a diagnosis of PTSD. Specifically, while in December 2004 the VA physician did not go into detail concerning the DSM-IV criteria necessary to support a diagnosis of PTSD, the VA physician clearly possesses the requisite medical training, expertise, and credentials needed to render a PTSD diagnosis. It is unclear whether the VA physician was a psychologist or psychologist, but the record was countersigned by a clinical psychologist. Further, the diagnosis appears to be based or least supported by psychological testing, as noted by the January 2005 VA record, which was conducted by a clinical psychologist and included PTSD as an axis I diagnosis. As for the Veteran's asserted stressors, the Board notes that the June 2012 PTSD stressor record mentioned previously appears to be verifying that the Veteran had fear of being subjected to SCUD missile attacks. Based on the available personnel records and the Veteran's statements, it is plausible that the Veteran witnessed or at least feared attacks from SCUD missiles, an event which in essence served as a stressor in support of the Veteran's PTSD diagnosis. See 38 U.S.C.A. § 1154(a). The March 2006 statement from Master Sergeant DH tends to at least support the Veteran's assertions concerning her inservice stressors. Resolving doubt in the Veteran's favor, the Board finds that the record establishes a current diagnosis of PTSD due to an inservice stressor that has been verified by the objective evidence of record. Service connection for PTSD and a depressive disorder is warranted. The Board notes that a few VA mental health treatment records have also noted a diagnosis of depressive disorder. The depressive disorder has not been dissociated from the Veteran's PTSD or military service. To the extent that such a disorder exists, the Board finds that the depressive disorder is either a manifestation/symptom of the PTSD or is related to her military service. VII. GERD At the November Board hearing the Veteran stated that she first had problems with her reflux condition when see had food poisoning during her deployment to Saudi Arabia. She indicated that she was treated with muscle relaxers. A June 1991 DA Form 2173 (Statement of Medical Examination and Duty Status) reflects that the Veteran reported having food poisoning in February 1991 while serving in Saudi Arabia. A September 1995 annual medical certificate reflects that the Veteran made no complaints related to a digestive disability. A November 2004 VA record noted that the Veteran was taking Omeprazole for her stomach problems. The diagnoses included GERD and dyspepsia. At the July 2012 VA examination it was noted that the Veteran had been diagnosed with GERD in 2000. She was taking medication (Omeprazole) and had GERD symptoms including pyrosis, reflux, regurgitation and sleep disturbances. The examiner stated that GERD with dyspepsia was less likely as not related to military service. There had been no evidence of GERD in the service and the gastrointestinal symptoms during service were due to a food related condition that was not the same as having GERD. The examiner noted that there was no medical evidence for any GERD condition until the year 2000. While medical records confirm that the Veteran has GERD, the Veteran's service treatment records do not indicate that the Veteran's GERD had its onset during active duty service. The Veteran's service treatment records simply reveal that the Veteran made complaints related to food poisoning. The Veteran's service treatment records do not indicate that the Veteran had GERD or any similar digestive disability. As for post-service medical evidence, the private and VA records do not show or contain any evidence suggesting a relationship between GERD and the Veteran's service. Significantly, the July 2012 VA examiner's opinion specifically noted that the Veteran's GERD was not to the Veteran's active duty service, including the incident of food poisoning. In support of the opinion the examiner noted that there was no evidence that GERD had been present during service or until the year 2000, many years subsequent to the Veteran's active duty service. Consideration has been given to the Veteran's assertions that her current GERD disorder is the result of the aforementioned in-service food poisoning incident. That is, although the Board readily acknowledges that Veteran is competent to report symptoms of stomach pain, there is no indication that the Veteran is competent to etiologically link her in-service food poisoning incident to her current GERD disorder, which was diagnosed many years after service. While it is true that the Veteran has had some level of medical training, the Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating digestive disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). As such, her opinion does not constitute competent medical evidence and lacks probative value. A review of the evidence has revealed that GERD did not have onset during her active service and was not caused by her active service. As the preponderance of evidence is unfavorable to the claim, the Board must deny the issue of entitlement to service connection for GERD. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for a right knee disability is denied. Service connection for left foot callus of the 5th metatarsal head disability is denied. Service connection for chronic sinusitis is denied. Service connection for a migraine headache disability is granted. Service connection for a lumbosacral strain disability is denied. Service connection for a psychiatric disorder, to include PTSD and depressive disorder, is granted. Service connection for GERD with dyspepsia is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs