Citation Nr: 1333694 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 10-01 505 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for peripheral neuropathy. 3. Entitlement to service connection for residuals of a right knee MCL tear. 4. Entitlement to service connection for other right knee disability, to include degenerative joint disease (DJD), patellofemoral syndrome and malalignment, and subluxation. REPRESENTATION Appellant (Veteran) represented by: Colorado Division of Veterans Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Christopher McEntee, Counsel INTRODUCTION The Veteran served on active duty from February 1966 to September 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The Veteran appeared before the undersigned Veterans Law Judge in a videoconference hearing in December 2012 to present testimony on the issues on appeal. The transcript was associated with the Veteran's virtual VA folder. In February 2013, the Board remanded this matter for additional medical inquiry. In Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Court of Appeals for Veterans Claims (CAVC) held that the scope of a disability claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. The CAVC recognized that, "the appellant had neither the legal or medical knowledge to narrow the universe of his claim or his current condition." Id. at 5. In this case, the Veteran has consistently contended that service connection is warranted for a right knee disability generally, without reference to specific diagnoses. The medical evidence now of record (specifically the May 2013 VA examination report) confirms several right knee diagnoses, including residuals of a MCL tear, degenerative joint disease, patellofemoral syndrome and malalignment, and subluxation. As will be discussed more fully below, the medical evidence supports service connection for one diagnosis, but not the others. Therefore, the Board has recharacterized the issue on appeal to cover all knee diagnoses. The Board notes that it has reviewed the Veteran's claims file, to include documents of record that have been included in his virtual VA folder. No new relevant evidence has been added to the claims file since the Supplemental Statement of the Case (SSOC) dated in August 2013. 38 C.F.R. §§ 19.31, 20.1304(c) (2012). The issue of entitlement to service connection for degenerative joint disease, patellofemoral syndrome and malalignment, and subluxation is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's current hearing loss is not related to the confirmed acoustic trauma he experienced during service. 2. The Veteran's current peripheral neuropathy is not related to his active service in general or, in particular, to his service in the Republic of Vietnam. 3. The Veteran as likely as not injured his right medial collateral ligament (MCL) during active service. CONCLUSIONS OF LAW 1. A bilateral hearing loss disorder was not incurred in or aggravated by active service, and may not be presumed related to service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2013). 2. Peripheral neuropathy was not incurred in or aggravated by active service, and may not be presumed related to service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 3. Residuals of a right knee MCL injury were incurred in service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA must provide notice and assistance to claimants for VA benefits. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. In the instant case, the Veteran was provided with satisfactory notice in May 2008. The letter informed the Veteran of the evidence and information necessary to substantiate his claims for service connection, and informed the Veteran regarding his and VA's respective responsibilities in obtaining evidence and information. The letter also informed the Veteran of the evidence and information necessary to establish a disability rating and an effective date. Further, the letter was provided to the Veteran prior to the initial unfavorable AOJ decision issued in August 2008. With regard to VA's duty to assist, the record indicates that in the notification letter, the RO requested from the Veteran information regarding medical evidence pertaining to his claims for service connection. The record shows that the RO included in the claims file the Veteran's service treatment records (STRs) as well as relevant private treatment records and reports. Furthermore, the Veteran underwent VA compensation examinations into his claims in July 2008 and May 2013, reports of which are of record. In each report, the VA examiner detailed the nature of the Veteran's disorder, indicated a review of the claims file, and noted findings based on the Veteran's lay statements, on the evidence of record, and on the examination of the Veteran. The findings are supported by data and reasoned explanations, moreover. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). As indicated in the Board's December 2012 remand, a July 2008 VA audiology report and opinion was insufficient. As will be detailed further below, that examiner provided in May 2013 an additional report and opinion which rectified the shortcomings noted in the July 2008 opinion. In sum, the Board finds that VA's duties to notify and assist have been substantially met. II. The Claims to Service Connection The Veteran contends that he incurred during active service bilateral hearing loss, peripheral neuropathy, and a right knee disability. The May 2013 VA compensation examination reports of record document that the Veteran has been diagnosed with hearing loss, neuropathy, and a right knee disability. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). The U.S. Court of Appeals for the Federal Circuit recently clarified that the continuity of symptomatology language in § 3.303(b) is limited to chronic diseases found in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Under 38 C.F.R. § 3.309(a), sensorineural hearing loss and arthritis are considered chronic diseases. 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). In assessing claims for service connection, the Board is required to render a finding with respect to the competency and credibility of the lay evidence of record. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competent, credible lay evidence could be, in and of itself, sufficient to establish an elemental fact necessary to support a finding of service connection. Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). A Veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses). Lay evidence may also be competent to establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F. 3d at 1377. Also, a veteran as a layman is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the layman is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F. 3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition; he or she is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Once competency is established, as a fact finder, the Board is also obligated to determine whether lay evidence is credible in and of itself. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, but it may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F. 3d 1331, 1336-1337 (Fed. Cir. 2006). Credibility is a factual determination going to the probative value of the evidence, to be made after the evidence has been admitted or deemed competent. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Hearing Loss Under VA guidelines, hearing loss will be considered a disability for compensation purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least 3 of the frequencies 500, 1000, 2000, 3000 or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The evidence of record indicates that the Veteran has a current hearing loss disorder and experienced acoustic trauma during service. The evidence of a current disorder is found in VA and private audiology examination reports of record dated in July 2008, December 2012, and May 2013, each of which notes auditory thresholds of at least 40 decibels in the relevant frequencies. Further, as noted in the Board's February 2013 grant of service connection for tinnitus, the evidence of in-service acoustic trauma is found in the Veteran's DD Form 214, in his lay statements during his testimony before the Board, and in written statements of record submitted in support of his claim. The Veteran contends that he experienced acoustic trauma as the result of exposure to weapons fire during training, his documented duties as an aircraft mechanic, exposure to weapons fire in Vietnam, and exposure to explosions from enemy attacks while serving in Vietnam. The Veteran is competent to attest to loud noises, which are observable, so the Board finds his contentions of probative value. Moreover, service treatment records document that the Veteran served with the U.S. Army in Vietnam during a time of war. Thus, his statements are consistent with the circumstances of his service. 38 C.F.R. § 3.159. The remaining question is whether his current hearing loss is related to the in-service noise exposure. In this case, the Board finds that the preponderance of the evidence of record is against a finding that the in-service acoustic trauma is related to the current hearing loss disability. The record contains four medical opinions addressing the claim, and each tends to counter the Veteran's contentions. The first opinion is dated in July 2008. In that opinion, the VA examiner stated that, based upon findings of normal hearing noted during active service (in the Veteran's discharge audiological examination), the Veteran's hearing loss was likely not related to service. In its February 2013 remand, the Board noted certain weaknesses with this opinion, in particular its heavy reliance on the Veteran's hearing capacity at discharge from service, and its apparent discounting of the demonstrated in-service acoustic trauma. See Hensley v. Brown, 5 Vet.App. 155, 159 (1993) (the lack of a demonstrated hearing loss disability in service "does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service.") Thus, in May 2013, the July 2008 VA examiner provided additional information regarding his opinion. As in July 2008, the examiner stated that the hearing loss was likely unrelated to service. In the May 2013 opinion, the examiner then elaborated on his opinion, explaining that audiological testing results in the Veteran's induction report of examination did not vary significantly from the audiological testing results noted in the discharge report of examination. In the May 2013 report and opinion, the examiner accepted that the Veteran was in fact exposed to "hazardous noise" during service. Nevertheless, the lack of a "significant threshold shift" from induction to discharge indicated no "hearing loss/hearing damage while in service." In support, the examiner cited a "landmark report" which posits that hearing disability should manifest immediately upon acoustic trauma and not "much later in one's lifetime[.]" The private medical evidence also contains commentary unfavorable to the Veteran's claim. First, in a December 2012 report, the Veteran's private audiologist stated that the Veteran "did not present with the typical configuration for noise induced hearing loss and that most noise induced hearing losses were not as asymmetric as his." The examiner further stated, "I am not comfortable" providing an opinion stating that the Veteran's hearing loss was as likely as not incurred during service because "I can not find any research or references" for such a finding. A subsequent private examination report conducted by a separate private examiner contained a review of the Veteran's history of in-service noise exposure. The examiner stated that the Veteran's left high-frequency hearing loss "can be noise induced." But the examiner also noted that the left low-frequency hearing loss "is usually not seen with noise induced hearing loss." In sum, three audiologists, in four opinions, commented on the Veteran's claim. Three of the opinions clearly lean against the Veteran's claim, while the latter December 2012 private opinion is a statement of mere possibility, rather than a medical opinion addressing probability. These opinions were rendered on the basis of a full review of the record, to include the Veteran's credible statements regarding his noise exposure. Reasonable rationales were offered to support the conclusions. As such, the Board places great weight on these opinions. Therefore, the Board finds that the medical evidence preponderates against the assertion that current hearing loss relates to in-service acoustic trauma. See Gilbert, supra. On the issue of medical nexus, the Board has also considered the Veteran's lay assertions, particularly his statements during his Board hearing, and his written statements submitted into the record, that the noise during service caused his current disability. As indicated earlier, the Veteran may be competent to testify regarding noise he hears and any limitation he experiences in his hearing. However, his assertion regarding the occurrence of a hearing loss disability during service, or soon after service, is of limited probative value because he is not competent to render such a determination, particularly given the strictures under 38 C.F.R. § 3.385. The inner-ear disability at issue involves an internal sensorineural pathology that is beyond the capacity for lay observation. Its etiology and development cannot be determined through observation or by sensation such as listening. The Veteran is simply not competent to render a medical opinion regarding the way in which his hearing loss developed. He does not have the training and expertise to provide medical evidence connecting service to the symptoms, or connecting the symptoms to the disorder at issue. The Veteran cannot provide evidence that states that what he experienced during service, or has felt since service, resulted in sensorineural hearing loss. On this essentially medical question, the Veteran's statements are not probative. Indeed, the statements of the three audiologists who considered his claim are of more probative value. Referable to the presumption for service connection for chronic diseases, the evidence would need to show that a diagnosis of sensorineural hearing loss was rendered within one year of the Veteran's 1968 separation, and that the severity of the disability reached the 10 percent level at that time. Here, the evidence does not confirm such a diagnosis in that time frame. Rather, the first documented diagnosis referable to the left ear is in 2004, and for the right ear, in 2005. Therefore, the presumption is inapplicable. In sum, the record demonstrates that the Veteran has a current bilateral hearing loss disorder under 38 C.F.R. § 3.385. However, the preponderance of the evidence of record demonstrates that he did not incur his hearing loss during service. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. Peripheral Neuropathy The Veteran maintains that exposure to herbicides while serving in Vietnam in the late 1960s led him to develop peripheral neuropathy. A Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, and who has one of the listed diseases under 38 C.F.R. § 3.309(e), shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. Effective September 6, 2013, 38 C.F.R. § 3.309(e) provides that early-onset peripheral neuropathy shall be service-connected even though there is no record of such disease during service. To qualify for presumptive service connection under this provision, the record needs to establish that the peripheral neuropathy became manifest to a degree of 10 percent or more within one year after the date of last exposure to herbicides. The record documents that the Veteran served in Vietnam in the late 1960s. However, by the Veteran's sworn testimony during his December 2012 hearing before the undersigned, his peripheral neuropathy symptoms began manifesting approximately 15 years following discharge from service. Indeed, the earliest medical evidence of peripheral neuropathy complaints, diagnosis, and treatment is dated in June 2003. The Board notes the Veteran's written statement of record dated in September 2013, and his reported statements noted in the May 2013 VA examination report, in which he now contends that he experienced peripheral neuropathy symptoms soon after leaving Vietnam, within one to one and a half years. However, the Board finds these statements lack credibility as they are directly contradicted by his statements under oath before the Board in December 2012. See Caluza v. Brown, 7 Vet. App. 498 (1995) (in weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness). Further, his lay opinion regarding onset of symptoms of neuropathy sufficient to warrant a diagnosis is of no probative value as he does not possess the competence to render such an opinion. 38 C.F.R. § 3.159. As such, presumptive service connection for early-onset peripheral neuropathy due to exposure to herbicides is not warranted under 38 C.F.R. § 3.309(e). The remaining inquiry in this decision will be limited to whether a direct service connection finding is warranted under 38 C.F.R. § 3.303. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996). As indicated earlier, the evidence establishes that the Veteran has a current neuropathic disorder. Specifically, the May 2013 VA examiner diagnosed the Veteran with distal symmetrical polyneuropathy (DSPN). However, the evidence of record does not indicate a neurological injury or disease during service. The Veteran's January 1966 induction report of medical examination found no neurological problems. The Veteran's STRs are negative for neurological problems. And the Veteran's September 1968 separation reports of medical examination and history are negative for neurological problems. Further, as indicated earlier, no medical evidence of record indicates a neurological disorder in the years following service. Rather, the earliest medical evidence of record of a neuropathic disorder is dated in June 2003, over 34 years following discharge from service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability may be considered in evaluating a claim of service connection). Furthermore, the only medical professional to comment on the Veteran's claim offered an opinion that challenges his theory of causation. In the May 2013 opinion addressing neuropathy, the examiner provided a clear opinion that the Veteran's polyneuropathy was not "due to an injury in service" to include herbicides exposure. Rather, she attributed the neuropathy to the Veteran's "longstanding HIV and anti-retroviral medication use." The examiner explained that DSPN was the "most common neurologic complication in HIV patients due to HIV and/or its treatment medications." The examiner noted that the Veteran began a multi-drug treatment regimen in 2003 after being diagnosed with HIV. Pursuant to the Board's request in the December 2012 remand, the May 2013 VA examiner also commented on evidence of record indicating that the Veteran may have experienced a nerve injury to the foot prior to service. In his January 1966 induction report of medical history, the Veteran noted "foot trouble" and "nerve injury to both feet" in June 1965 while vacationing in Europe. The physician's summary of the report indicated "sensitive" feet. Though this information is not evidence of neuropathy, the Board nevertheless sought medical commentary on its significance. In response, the May 2013 VA examiner noted the Veteran's reported history, that "6 months before enlistment, he had walked a lot on a Europe trip with a college buddy. It made his feet feel sore. It went away after a week back from the trip." The examiner stated that the "history is consistent with dysasthesias due to plantar fasciitis from all the walking he did while in Europe for 6 months which resolved after resting." The examiner then commented that the Veteran's STRs indicated "no continued problems with plantar fasciitis while in service." Further, the examiner stated that the "DSPN is not due to nor related to his history of plantar fasciitis from excessive walking." Based on this medical opinion - and on the absence of lay or medical evidence asserting the existence of a pre-service neuropathic disorder - an inquiry into whether a neuropathic disorder was aggravated by service is unnecessary here. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. The Board finds the May 2013 VA opinion to be of significant probative value. The examiner indicated a review of the relevant evidence of record, indicated a personal assessment of the Veteran, and indicated evaluation of the Veteran's lay statements regarding his symptoms. Moreover, the examiner supported her opinion with a rationale. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (a physician's statement is dependent, in part, upon the extent to which it reflects clinical data or other rationale to support the opinion). While the Board recognizes that the Veteran is competent to speak to the onset of his symptoms, given his conflicting statements on that subject, the Board finds that the medical explanation is far more probative on the issue of nexus than his current contentions. In sum, the record demonstrates that the Veteran has current polyneuropathy. However, the preponderance of the evidence of record demonstrates that he did not experience a neuropathic disorder during service that relates to the current disorder. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. Right Knee As noted in the introduction, the medical evidence documents that the Veteran has several diagnosed disorders of his right knee. Private treatment records dated since 2007 note "severe" patellofemoral malalignment. Further, the May 2013 VA examiner diagnosed the Veteran with right knee patellofemoral syndrome, subluxation, degenerative joint disease, and an "old" and "healed" MCL injury based on "radiographic evidence." With regard to whether the Veteran had a right knee injury during service, the Board finds the evidence to be in equipoise. See Gilbert, supra. On the one hand, the Veteran's STRs, to include the September 1968 discharge reports of medical examination and history, are negative for a right knee disorder. Further, the earliest medical evidence of record of a right knee disorder is found in private treatment records dated in 2007, nearly 40 years after service. In fact, private medical records dated in 2003, which address a left knee disorder, indicate no right knee disorder and no prior knee problems, while private treatment records dated in 2007, which do mention a right knee disorder, report an onset of pain 4-5 years earlier. See Maxson, supra. On the other hand, the Veteran has consistently asserted in lay statements of record throughout the appeal that he injured his right knee during service as the result of jumping from a military aircraft. Moreover, he has described experiencing a continuity of symptomatology of a right knee disability since discharge from service. These statements are of probative value because right knee pain and limitation of motion concern observable symptoms regarding which the Veteran is competent to testify. See Layno, supra. Further, the Veteran's statements of record regarding the way in which he injured his right knee are consistent, and therefore credible. See Caluza, supra. Thus, the Board finds the evidence in equipoise regarding the issue of whether the Veteran injured his right knee during service, and will proceed by giving him the benefit of the doubt on this element. The record also supports his assertion that a current right knee disorder relates to service. The only medical professional of record to comment on the issue of medical nexus supports the Veteran's theory of entitlement. The May 2013 VA examiner stated that it was "at least as likely as not that the Veteran's evidence of old MCL tear is related to his report of the fall while in service with the twisting mechanism he reports that could have caused a significant valgus stress to tear the MCL and cause the initial swelling/pain/limited use of right leg." The examiner proceeded to characterize the MCL injury as "an old injury that has healed without residuals." The examiner indicated that the MCL tear "has resolved without evidence of residual laxity of ligament." And the examiner found "no residuals" based on "normal valgus stress testing." Nevertheless, a service connection finding is warranted irrespective of the degree of disability associated with the MCL tear. As stated by the examiner, radiographic evidence demonstrates an old tear. That tear, albeit asymptomatic, should be service-connected. 38 C.F.R. § 3.303. Notably, the examiner explained the underlying reasons for the opinion referable to the MCL disability. The Board finds the explanation reasonable and not contradicted by the record. Therefore, significant weight is placed on the opinion. Hence, the evidence supports a finding of direct service connection for residuals of an MCL tear. As will be discussed in the remand section below, the evidence as it stands now does not support a finding of service connection for right knee patellofemoral syndrome and malalignment, right patellar subluxation, or right knee degenerative joint disease. However, additional development is required prior to final appellate disposition. ORDER Service connection for bilateral hearing loss is denied. Service connection for peripheral neuropathy is denied. Service connection for residuals of a right MCL tear are granted. REMAND The theory of entitlement to service connection on a secondary basis has now been raised by the record. The Veteran has not yet been provided satisfactory notice of the requirements of substantiating such a claim. As such, it would be prejudicial to the Veteran for the Board to proceed with final disposition of this issue as of yet. With the decision herein, service connection is granted for residuals of a right MCL tear. The Board recognizes that the current evidence demonstrates that this disability is asymptomatic. However, because the Board cannot substitute its own medical judgment for that of trained medical professionals, the evidence as it currently stands requires further clarification. Specifically, while the May 2013 VA examination of the right knee and resultant opinion are clear on causation of the remaining knee disabilities of record, it is less clear on whether those disabilities have been aggravated by the now service-connected residuals of a right MCL tear. Thus, an addendum is required. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with notice as to how to substantiate a claim for secondary service connection for right knee patellofemoral syndrome and malalignment, right patellar subluxation, and right knee degenerative joint disease. 2. Forward the Veteran's claims folder to the examiner who conducted the May 2013 VA knee examination (or a suitable substitute if this individual is unavailable) for an addendum. The examiner is requested again to review the claims folder in order to clarify whether it is at least as likely as not that the Veteran's right knee patellofemoral syndrome and malalignment, right patellar subluxation, and/or right knee degenerative joint disease have been aggravated by his now service-connected residuals of a right MCL tear. The examiner is reminded that aggravation means that there is a permanent worsening of the disability beyond its natural progression. Additionally, the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. The underlying reasons for the opinion must be included. 3. Thereafter, readjudicate the issue on appeal. If the determination remains unfavorable to the Veteran, he and his representative should be furnished a supplemental statement of the case which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and his representative should be afforded the applicable time period in which to respond. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs