Citation Nr: 1337867 Decision Date: 11/19/13 Archive Date: 12/06/13 DOCKET NO. 10-22 281 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to service connection for a right shoulder disability. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for a bilateral foot disability, to include pes planus (flat foot). 4. Entitlement to service connection for sleep apnea. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from December 1977 to October 1981. These matters are before the Board of Veterans' Appeals (Board) on appeal from March 2009 and April 2010 rating decisions of the Waco, Texas RO. In February 2012, a videoconference hearing was held before the undersigned; a transcript of the hearing is in the claims file. At the hearing the Veteran requested, and was granted, a 60 day abeyance period for the submission of additional evidence; no additional evidence was received and the 60 day period lapsed. In April 2012, the Board remanded the matters for additional development. The claims folder contains a February 2009 Formal Finding on the Unavailability of STRs for the Veteran, noting that the RO had sent a request to the National Personnel Records Center and received an empty folder in response in January 2009, the RO had sent letters to the Veteran requesting records from her in December 2008 and a second letter requesting alternate source letters from the Veteran in January 2009, but no records were received. However, in April 2009 she submitted 96 pages of STRs (which she stated she had received from the national archives). In April 2012 the Board remanded the case for an exhaustive search for the Veteran's complete STRs, as well as to obtain any outstanding VA treatment records from before April 2008. The claims file now includes an April 2013 Formal Finding by the AMC/RO that records of any treatment the Veteran received at the Fort Lee Army Hospital from January to December 1977 and at the Frankfurt and Army Hospital from January to December 1980 as well as records of any treatment she received at El Paso VA Medical Center from October 1981 through March 2008 are unavailable. The issue of service connection for bilateral hearing loss is being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action on her part is required. FINDINGS OF FACT 1. A chronic right shoulder disability was not manifested in service; arthritis of the right shoulder was not manifested in the first year following the Veteran's discharge from active duty; and a right shoulder disability is not shown to be related to the Veteran's service. 2. A foot disability was not manifested in service; arthritis of either foot was not manifested in the first year following the Veteran's discharge from active duty; and a disability of either foot is not shown to be related to the Veteran's service. 3. Sleep apnea was not manifested in service; and the preponderance of the evidence is against a finding that such disability is related to the Veteran's active service. CONCLUSIONS OF LAW 1. Service connection for a right shoulder disability is not warranted. 38 U.S.C.A. §§ 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2013). 2. Service connection for a bilateral foot disability is not warranted. 38 U.S.C.A. §§ 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2013). 3. Service connection for sleep apnea is not warranted. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to their initial adjudication. December 2008, January 2009, and January 2010 letters explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence she was responsible for providing. These letters also informed her of disability rating and effective date criteria. She has had ample opportunity to respond/supplement the record and has not alleged that notice in these matters was less than adequate. The Veteran's available service treatment records (STRs) and available pertinent postservice treatment records have been secured. She has stated that she received treatment in service at the Army hospitals in Frankfurt, Germany and Fort Lee, Virginia while. She has also stated that she received treatment at the El Paso VA Medical Center prior to 2008. However, such records are certified to be unavailable. When VA treatment records are lost or missing, VA has a heightened obligation to satisfy the duty to assist. Here, the claims file includes a April 2013 memorandum indicating that there are no treatment records available for the Veteran from the two cited Army hospitals, and there are no VA treatment records available from before April 2008, and an April 2013 Formal Finding on the Unavailability of Records indicating the same. The United States Court of Appeals for Veterans Claims (Court) has held that VA has a heightened duty "to consider the applicability of the benefit of the doubt rule, to assist the claimant in [otherwise] developing the claim, and to explain its decision when the veteran's medical records have been destroyed." Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005) citing Russo v. Brown, 9 Vet. App. 46, 51 (1996). However, no presumption, in favor of the claimant or against VA, arises when there are lost or missing service records. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005). The RO arranged for VA examinations in April 2010 and May 2012. As will be discussed in greater detail below, the Board finds these examinations to be adequate, as they included a thorough review of the Veteran's medical history, physical examinations noting all pertinent findings, and medical opinions with adequate supporting rationale. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims file and in Virtual VA (VA's electronic data storage system) 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 as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Service connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). In order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) evidence of incurrence or aggravation of a disease or injury in service; and (3) evidence of a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Disorders diagnosed after discharge may still be service connected if all the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Certain chronic disabilities (including arthritis) may be service-connected on a presumptive basis if manifested in a specified period of time following a veteran's discharge from active duty (one year for arthritis). 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is needed where the determinative question is one requiring medical knowledge. Id. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. It may also mean statements conveying sound medical principles found in medical treatises, and may include statements in authoritative writings, such as medical and scientific articles and research reports. 38 C.F.R. § 3.159(a)(1). 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 layperson. 38 C.F.R. § 3.159(a)(2). Right shoulder disability The Veteran claims that she has a chronic right shoulder disability that was incurred in service. The available STRs show that the Veteran complained of right shoulder problems in service. In March 1981, while stationed with the 9th Medical Detachment in Europe, she complained of right shoulder pain for two days with some pain on abduction; the assessment was bursitis vs. strain of the acromioclavicular joint. Treatment consisted of heat and a sling. On April 2008 VA treatment, chest X-rays showed probable postoperative changes of the right shoulder with degenerative process. On July 2008 VA treatment, the Veteran's past medical history was noted to include fibromyalgia and mixed connective tissue disorder. A right rotator cuff repair was noted in 2006. She complained of multiple joint pains, particularly cramps in her hands and feet. On physical examination, there were no joint deformities, yet there was limited range of motion and tenderness of the joints. The assessments included fibromyalgia and mixed connective tissue disorder. On November 2008 VA treatment, the Veteran complained of right shoulder pain, stating that Mobic was ineffective for pain relief. On April 2010 VA treatment, the Veteran was noted to have sustained a fall in 2005 resulting in a right shoulder injury. On April 2010 VA examination, the Veteran reported that her shoulder pain began in 1979 due to repetitive motion and carrying a weapon. She reported that she was given NSAIDs in service through separation. She reported that more recently she injured her right shoulder in a fall and developed a rotator cuff tear, for which she underwent surgical correction; the examiner noted a history of rotator cuff arthroscopy in 2006 in El Paso. The Veteran reported that she continued with progressively worse shoulder pain, especially in cold weather. X-rays showed probable postoperative changes to the right shoulder with degenerative process. Following a physical examination, the diagnosis was right shoulder condition, rotator cuff tear, repaired. The examiner noted that a review of the claims file confirmed a right shoulder complaint, evaluation, and treatment in service, but no injury, as well as evaluation and treatment of a rotator cuff tear which occurred after separation from service. The examiner opined that the Veteran's right shoulder condition is less likely as not (less than 50/50 probability) caused by or a result of the shoulder complaints in service. The examiner explained that the claims file confirms a complaint of right shoulder evaluation and treatment in service but no injury, and evaluation and treatment of a rotator cuff tear which occurred after separation. The examiner noted that the fact that there was no evidence of shoulder complaints between the in-service and post-service episodes suggested no service connection. On June 2011 VA treatment, the Veteran complained of right shoulder pain. At the February 2012 videoconference hearing, the Veteran testified that she began having pain to the right shoulder during service and had trouble moving it. She testified that there was no specific injury to the shoulder, and that the problems "just started" while she was in Advanced Individual Training (AIT). She testified that she sought treatment for the shoulder once or twice while serving in Germany, and was given anti-inflammatories and told to rest. She testified that she has had continual problems with the right shoulder over the years but has treated it with heat and tried to live with the pain. She testified that she fell a few years ago and sustained a torn rotator cuff, for which she sought treatment. On May 2012 VA examination, the Veteran reported that she developed pain in the right shoulder in about 1980 or 1981 with no trauma; she was seen and told it could be due to bursitis and treated with NSAIDs but the pain persisted. She reported that in 2005 she fell and tore her right rotator cuff; she had surgery twice to repair the shoulder but still has pain. She reported no current treatment for the shoulder but the pain was constant and worse with lying down. X-rays of the right shoulder showed a single anchor in the anatomic neck of the proximal humerus; the shoulder was otherwise unremarkable. The Veteran had worked as a nurse but stopped one year earlier due to medical retirement for fibromyalgia. The diagnosis was residuals after a right shoulder rotator cuff repair. The examiner opined that the nature and likely etiology of the right shoulder condition is residuals from the torn rotator cuff in 2005. The examiner noted that the claims file shows a single visit for two days of right shoulder pain in service that was treated conservatively, and she denied any trauma; no further documentation of a chronic problem in service is provided. The examiner opined that the rotator cuff tear resulted from a fall decades after discharge from service. The Veteran submitted VA and private treatment records through 2013 showing findings similar to those on the VA examinations outlined above. The records show ongoing treatment for right shoulder problems, with no opinions regarding etiology. Notably, the Board's April 2012 remand instructed the RO to obtain records of the alleged service treatment in 1980 or 1981. An April 2013 memorandum includes a formal finding of unavailability of the Veteran's complete STRs and clinical records from treatment while on active duty in Germany. The Board finds that the April 2010 and May 2012 VA examiners' opinions are entitled to great probative weight, as they reflect a thorough review of the Veteran's complete medical history and statements included in the claims file and include detailed explanations of rationale, with citation to factual evidence, and identify alternate nonservice-related etiological factors for the Veteran's right shoulder disability, including a documented postservice injury in 2005 with subsequent surgery in 2006. A chronic right shoulder disability was not diagnosed in service or postservice until approximately 2005 (24 years after the Veteran's separation from active duty service). While she has reported (including on VA examination) that she has had continuous right shoulder problems since an injury in service, and in some medical records she has attributed her current right shoulder complaints to such injury, her accounts have been inconsistent and self-serving, and are deemed not credible. Where contemporaneous records would be expected to provide support for the Veteran's accounts, they do not. For example, as the Veteran apparently worked as a nurse for many years postservice, it would be expected that if she had a significant right shoulder disability since service, it would have been evaluated/treated by a medical professional during the long postservice interval prior to her 2005 injury. That it was not weighs against the credibility of her accounts of ongoing, disabling symptoms since service. Accordingly, service connection for a right shoulder disability on the basis that such disability became manifest in service, and persisted, is not warranted. Inasmuch as there is no evidence that arthritis of the right shoulder was manifested in the first year following the Veteran's separation from active duty, service connection for such disability on a presumptive basis (as a chronic disease under 38 U.S.C.A. §§ 1112, 1137) likewise is not warranted. The Board finds further that the preponderance of the evidence is against the Veteran's claim seeking service connection for a right shoulder disability. His STRs are silent regarding any chronic right shoulder disability. The only medical evidence that directly addresses the matter of a nexus between the Veteran's current right shoulder disability and her service/injury(ies) therein, with adequate supporting rationale, is in the reports of the April 2010 and May 2012 VA examinations, wherein the examiners opined that the Veteran's right shoulder complaints are unrelated to her service or any injury therein. The physicians noted the history of the claimed and diagnosed disabilities and thoroughly explained the rationale for the opinions. The Board finds this evidence highly probative in the matter at hand (as the examiners are medical professionals qualified to provide them and support them with explanation of rationale and citation to supporting factual data, and identify an alternate etiology for the disability considered more likely, namely the postservice injury). Because there is no competent (medical opinion/treatise) evidence to the contrary, the Board finds the April 2010 and May 2012 VA examiners' opinions to be persuasive. In the absence of credible evidence of continuity of symptoms, the Veteran's own assertions that there is a nexus between her current right shoulder disability and an injury or injuries in service are not competent evidence. The etiology of an insidious process such as arthritis, bursitis, or a rotator cuff tear is a matter beyond the capability of lay observation, but is a complex medical question that requires specific medical knowledge/training (and diagnostic studies). See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Veteran is a nurse and by virtue of the training required for such profession possesses some medical knowledge; however, she does not cite to supporting factual data, an orthopedist's medical opinion or treatise evidence that would support a nexus between her current right shoulder disability and her remote service/complaints therein. She does not provide an adequate explanation of rationale for her theory or entitlement (other than alleging of continuity of symptoms, which the Board has found not credible). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for a right shoulder disability. Accordingly, the appeal in the matter must be denied. Bilateral foot disability The Veteran contends that she has a chronic bilateral foot disability, specifically pes planus, that was incurred in service. Her available STRs are silent for any complaints, findings, treatment, or diagnosis regarding any foot disability including pes planus. No service separation examination is available for review. On November 2008 VA treatment, the Veteran complained of right foot pain and progressive left foot pain; the assessment was bilateral foot pain. April 2009 X-rays of the bilateral feet revealed calcaneal spurring bilaterally. On July 2009 VA treatment, the Veteran complained of bilateral foot pain. On April 2010 VA podiatry consult, the Veteran complained of burning pain in the heel areas and on the balls of both feet. She reported that she had worn shoe inserts in the past but they had hurt her feet. She was noted to have a history of fibromyalgia. Following an orthopedic examination, a flat feet deformity was noted. On August 2010 VA treatment for diabetic foot care, it was noted that the Veteran had been wearing foot orthotics with some support for her feet condition. Following a physical examination, the assessments included flat feet. On November 2010 VA treatment for diabetic foot care, the Veteran was noted to have a history of severe flat feet. She complained of a sharp needle-like pain on the medial aspect of both ankles as well as a burning and tingling sensation on the medial aspect of the medial arch bilaterally. The assessments included flat feet and rule-out tarsal tunnel syndrome. On May 2011 VA treatment, the Veteran reported discomfort in the feet when walking. The diagnoses included probable plantar fasciitis, and it was noted that sensory neuropathic changes due to diabetes may be contributing to her discomfort. On August 2011 VA treatment, the Veteran reported pain in both heels that was improving. The assessments included improving bilateral plantar fasciitis. At the February 2012 videoconference Board hearing, the Veteran testified that she was treated for flat feet while stationed at Frankfurt Army Hospital in Germany during service. She testified that she was given custom-made leather inserts for both feet based on her complaints of pain and swelling in the feet, although the inserts only made the problem worse so she did not wear them after two weeks. She testified that she went to sick call many times with complaints regarding her feet, and had to do remedial physical training because she could not run in the time allotted due to foot pain. She testified that her foot problems began while she was in AIT and had worsened and continued to the present day. She testified that she began seeking treatment with VA podiatrists at least three years ago (approximately 2009) and currently received treatment about every three months. On March 2012 VA treatment, the Veteran reported foot pain. She was retired, which helped with her foot pain. The assessments included bilateral plantar fasciitis. On May 2012 VA examination, the Veteran reported that she developed pain in both feet in the 1970s, particularly when she had to walk long distances or run. She reported that she was seen and told the problem was due to flat feet, but inserts made it worse. She reported continuing pain in the feet and she was treated in podiatry. She had orthotic inserts, but they were causing pain. She was noted to have bilateral pes planus but the weight-bearing was not medial to the great toe; she reported that the source of her pain was the insertion of the plantar fascia bilaterally, and the area was tender to palpation. Notably, she stated that her pes planus was lifelong. She reported constant use of a cane (for balance following a stroke) and orthotics. The diagnosis was bilateral plantar fasciitis. The examiner opined that the most likely etiology for the Veteran's plantar fasciitis is the combination of her pes planus and morbid obesity both putting excess pressure on the plantar fascia. The examiner could not resolve the issue of whether the problem was incurred in service without resort to speculation, as the STRs appeared incomplete and contained no visits for foot pain as described by the Veteran, and the Veteran reported that the pes planus problem was lifelong. On July 2012 VA treatment, the Veteran reported that she needed a new pair of orthotics; the assessments included bilateral plantar fasciitis with some improvement. On January 2013 VA treatment, the Veteran complained of a burning sensation at times during the day on the bottom of both feet. The Veteran has also submitted VA treatment records through 2013 showing findings similar to those on the VA examination outlined above. The Board finds that the May 2012 VA examiner's opinion is entitled to great probative weight, as it reflects a complete review of the Veteran's complete medical history and statements included in the claims file and includes a detailed explanation of rationale. A chronic bilateral foot disability was not diagnosed in service or postservice until approximately 2010, some 29 years after the Veteran's separation from active duty. While she has reported (including on May 2012 VA examination) that she has had continuous bilateral foot problems since service, and in medical records since November 2008 has attributed her current bilateral foot complaints to such injury, her accounts have been inconsistent and are self-serving. Furthermore, where contemporaneous records would be expected to provide support for the accounts, they do not. The Veteran has not reported seeking foot treatment postservice prior to approximately 2009, as would be expected with a significant longstanding bilateral foot problem. Reasonably, a continuous significant foot disability that began in service would have been evaluated/treated sooner postservice than 28 or 29 years as shown in this case (and acknowledged by the Veteran). Consequently, the Board finds her reports of bilateral foot symptoms existing ever since service to be self-serving and not credible. Consequently, service connection for a bilateral foot disability on the basis that such disability became manifest in service, and persisted, is not warranted. Inasmuch as there is no evidence that bilateral foot arthritis was manifested in the first year following the Veteran's separation from active duty, presumptive service connection for such disability (as a chronic disease under 38 U.S.C.A. §§ 1112, 1137) likewise is not warranted. The Board finds further that the preponderance of the evidence is against the Veteran's claim seeking service connection for a bilateral foot disability, including pes planus/flat foot. There is no evidence that she sustained a foot injury in service that may have resulted in any chronic bilateral foot pathology/disability. The only medical evidence that directly addresses the matter of a nexus between the Veteran's current bilateral foot disability and her service/injury therein, with adequate supporting rationale, is the report of the May 2012 VA examination, when the examiner opined that the Veteran's bilateral foot complaints are unrelated to her service or any injury therein. The physician noted the history of the claimed and diagnosed disabilities and thoroughly explained the rationale for the opinion. The Board finds this evidence highly probative in the matter at hand (as the examiner is a medical professional qualified to provide it and supports it with explanation of rationale and citation to supporting factual data). Because there is no competent (medical opinion/treatise) evidence to the contrary, the Board finds the May 2012 VA examiner's opinion to be persuasive. In the absence of credible evidence of continuity of symptoms, the Veteran's own assertions that there is a nexus between her current bilateral foot disability and an injury in service are not competent evidence. The etiology of the foot disorders shown, arthritis, pes planus, or plantar fasciitis, is a medical question that requires some specific medical knowledge. See Jandreau v. Nicholson, supra. The Veteran has been a nurse (and therefore has received some medical training); however, she does not explain the rationale for her opinion (other than alleging continuity of symptoms, which the Board has rejected as not credible), and she does not cite to supporting factual data or treatise evidence. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for a bilateral foot disability, including pes planus/flat foot. Accordingly, the appeal in the matter must be denied. Sleep apnea The Veteran contends that she has a current sleep apnea disability that was incurred in service. The available STRs are silent for any complaints, findings, treatment, or diagnosis regarding sleep problems; no service separation examination is available for review. A March 2009 private sleep study noted that the Veteran had a significant medical history of sleep apnea. She presented with a history of restless and disturbed sleep, heavy snoring associated with dry mouth, and severe daytime sleepiness. The impressions included moderate obstructive sleep apnea with severe oxygen desaturations and severe snoring. On April 2009 VA treatment, the Veteran was provided a CPAP machine. In a December 2009 statement, the Veteran stated that for years she recalled complaining of feeling tired even after getting what she thought had been a good night's sleep. She stated that she had been hospitalized at Fort Lee for a few days during service in attempts to find a diagnosis for her symptoms, which included feeling tired after sleeping at night and loud snoring which at times woke her up. She stated that her husband would elbow her and say she was either snoring too loudly or gasping for air or had stopped breathing. She noted that she had mononucleosis diagnosed at Fort Lee, but her symptoms continued through the remainder of her active duty and thereafter. She was told then that she was anemic. She stated that, after many years with these symptoms, she began seeing a rheumatologist for increasing chronic pain, and he recommended that she undergo a sleep study. She stated that moderate sleep apnea was diagnosed based on the sleep study, and was given a CPAP machine. She stated that her symptoms of daytime sleepiness and the feeling of falling asleep while driving continued even with the use of the CPAP machine but had improved. In a February 2010 statement, the Veteran's estranged husband stated that he had known the Veteran for 31 years; he stated that throughout that time she had complained of feeling worn out and tired and would often doze off during the day, even while driving. He stated that he had asked her not to drive. He stated that she had had problems with snoring and at times would even pause breathing or snoring for a few seconds and then make a loud gasping sound. He stated that she had been to sick call numerous times when they were both in service because of the tiredness, feeling worn out, and "falling asleep all the time". He stated that she was told her symptoms were due to being anemic. On April 2010 VA examination, the examiner noted that the Veteran was hospitalized in March 1978 for anemia with complaints of recurrent fever and fatigue; the examiner noted the Veteran's report that she was hospitalized at Fort Lee for mononucleosis yet her fatigue continued. The diagnosis following a physical examination was anemia in remission. In a July 2010 statement, the Veteran stated that she had been hospitalized for approximately one week at the Fort Lee hospital for mononucleosis based on her complaints of always feeling tired and not rested, and waking up during the night. At the February 2012 videoconference Board hearing, the Veteran testified that she began having sleep problems while on active duty; she testified that her husband complained that she snored and sounded like she was trying to catch her breath during the night while sleeping, and she usually felt very tired during the day. She testified that she complained about this problem when she was treated at the hospital at Fort Lee, Virginia, and was told she had mononucleosis and then anemia; she testified that the anemia resolved yet her symptoms continued. She testified that she was hospitalized at Fort Lee for about three days while she was in AIT. She testified that she had difficulty falling asleep and staying asleep, and she was always tired during the day because she did not really sleep during the night. She testified that no sleep studies were recommended while she was in service; sleep apnea was diagnosed based on a VA sleep study in 2005 after her rheumatologist recommended one be performed. On May 2012 VA examination, the diagnosis was obstructive sleep apnea with a March 2009 date of diagnosis following a sleep study. The Veteran reported that she had daytime fatigue and snoring in the 1970s; at that time, she was seen for fatigue and treated for mononucleosis and anemia. She reported that a sleep study several years prior showed sleep apnea. The Veteran reported using a CPAP machine and also took Ambien and clonazepam for insomnia. Her current symptoms attributable to sleep apnea included persistent daytime hypersomnolence. She was noted to be morbidly obese. The examiner opined that the most likely etiology for the Veteran's sleep apnea is her morbid obesity; the examiner noted that this is by far the biggest risk factor for such problem. The examiner could not opine as to when the issue arose without resort to speculation, as the STRs appeared incomplete and there was no information between the Veteran's service and several years ago. There was no information in the records provided about snoring or chronic fatigue in service. The examiner noted that the Veteran was hospitalized for anemia for a week in service but no details were provided; however, anemia is another cause of fatigue. The evidence includes additional VA and private medical records through 2013 noting continuing sleep apnea, with no opinions offered regarding etiology. The Board finds that the April 2010 and May 2012 VA examiners' opinions (cumulatively) are entitled to great probative weight, as they reflect a complete review of the Veteran's complete medical history and statements included in the claims file and include detailed explanations of rationale. Sleep apnea was not diagnosed in service or postservice until approximately 2009, or 28 years after the Veteran's separation from active duty service. While she has reported that she has had continuous sleep problems since service, her accounts have been inconsistent and are self-serving. Furthermore, where contemporaneous records would be expected to provide support for the accounts, they do not. Consequently, the Board finds her reports of sleep apnea symptoms existing ever since service to not be credible. The Veteran has not reported seeking sleep apnea treatment postservice prior to 2009. Regarding the lay statement from the Veteran's estranged husband attesting that the she had sleep apnea while on active duty, the Board accepts it as credible corroboration that she snored in service. However, whether or not the snoring was a symptom of obstructive sleep apnea is a medical question. The diagnosis of sleep apnea is not one that can be made by lay observation; it requires medical expertise/diagnostic studies. No medical provider has opined that complaints of snoring in service of themselves support a diagnosis of sleep apnea for the Veteran when she was on active duty. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009. Although she has been a medical professional, her opinion to that effect is unaccompanied by rationale/citation to supporting factual data/medical literature, and is therefore lacking in probative value. Consequently, service connection for sleep apnea on the basis that such disability became manifest in service, and persisted, is not warranted. The Board finds further that the preponderance of the evidence is against the Veteran's claim otherwise seeking service connection for sleep apnea. The only probative evidence that directly addresses the matter of a nexus between the Veteran's current sleep apnea and her service, and is accompanied by adequate explanation of rationale is in the reports of the April 2010 and May 2012 VA examinations, wherein the examiners opined that the Veteran's sleep apnea complaints are unrelated to her service. The physicians noted the history of the claimed and diagnosed disability and thoroughly explained the rationale for the opinions, identifying alternate, nonservice-related, etiological factors present. The Board finds this evidence highly probative in the matter at hand (as the examiners are medical professionals qualified to provide them and support them with explanation of rationale and citation to supporting factual data). Because there is no competent (medical opinion/treatise) evidence to the contrary, the Board finds the April 2010 and May 2012 VA examiners' opinions to be persuasive. In the absence of credible evidence of continuity of symptoms, the Veteran's own assertions that there is a nexus between her current sleep apnea and service are not competent evidence; they are unaccompanied by any rationale (other than on the basis that the disability became manifest in service and persisted, which the Board has rejected). The etiology of a pulmonary/respiratory process such as sleep apnea is a complex medical question that requires medical knowledge/training. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Veteran may be a medical professional, but her opinion is unaccompanied by an adequate explanation of rationale (notably, she does not account for the nonservice-related etiological factors for sleep apnea shown in this case which VA examiners have identified as the more likely etiology for her sleep apnea). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for sleep apnea. Accordingly, the appeal in the matter must be denied. ORDER Service connection for a right shoulder disability is denied. Service connection for a bilateral foot disability, to include pes planus is denied. Service connection for sleep apnea is denied. EMAND The Board has reviewed the Veteran's claims file as well as Virtual VA. On review of the record, the Board finds that the matter of service connection for bilateral hearing loss must again be remanded for evidentiary development. The Veteran contends that her hearing acuity was damaged by her service as a supply clerk in the motor pool while stationed in Germany, exposing her to noise trauma from constant generators and trucks without the benefit of any kind of hearing protection. Audiometry on May 2012 VA audiological examination did not show a hearing loss disability by VA standards (as defined in 38 C.F.R. § 3.385), and service connection has been denied essentially on the basis that the claimed disability was not shown. However, the Board notes that on June 2009 VA treatment, the diagnosis following an audiological evaluation was bilateral sensorineural hearing loss of combined types. Additionally, on October 2012 VA treatment, the diagnosis was bilateral sensorineural hearing loss of combined types. The treating audiologist noted that the previous June 2009 evaluation indicated mild sensorineural hearing loss bilaterally (within normal limits from 1500 to 3000 Hertz in the right ear and from 500 to 3000 Hertz in the left ear); she had been fitted for hearing aids at that time. Puretone audiometry in October 2012 indicated mild sensorineural hearing loss at 2000 Hertz and above 3000 Hertz in the right ear, and at 250 Hertz and above 1500 Hertz in the left ear. Word recognition scores were 88 percent bilaterally, reflecting a hearing loss disability in each ear (as defined in 38 C.F.R. § 3.385). The discrepancy in the findings must be reconciled. Accordingly, the case is REMANDED for the following action: 1. The RO should return the claims file to the VA audiologist who conducted the May 2012 examination of the Veteran to reconcile the conflicting reports noted above regarding whether or not she has a hearing loss disability (as defined in 38 C.F.R. § 3.385), and if so its likely etiology (specifically whether it is related to her service). The Veteran's claims file (to include this remand) must be reviewed by the examiner in conjunction with the examination. Based on a review of the record and examination/interview of the Veteran, the examiner must offer opinions that respond to the following: (a) Does the Veteran have a hearing loss disability as defined in 38 C.F.R. § 3.385? The explanation of rationale for the opinion should (to the extent possible) reconcile the conflicting findings in that regard made on May 2012 VA examination, and on June 2009 and October 2012 VA treatment. (b) If a hearing loss disability is found, the examiner should further opine whether such disability is at least as likely as not (a 50 % or better probability) related to the Veteran's acknowledged exposure to noise trauma in service. The examiner must explain the rationale for the opinion in detail; if the opinion is to the effect that the hearing loss is unrelated to service, the explanation should identify other (considered more likely) possible etiologies for the hearing loss. 2. The RO should then review the record and readjudicate the claim of service connection for bilateral hearing loss. If it remains denied, the RO should issue an appropriate supplemental statement of the case, and afford the Veteran and her representative opportunity to respond. The case should then be returned to the Board, if in order, for further review. 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs