Citation Nr: 1432136 Decision Date: 07/17/14 Archive Date: 07/22/14 DOCKET NO. 08-02 650 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a left long finger disability. 2. Entitlement to service connection for a right hip disability. 3. Entitlement to service connection for left knee disability. 4. Entitlement to service connection for gout. 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for bilateral tinnitus. 7. Entitlement to service connection for a heart disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Devon Rembert-Carroll, Associate Counsel INTRODUCTION The Veteran had active military service from July 1975 to August 1979 with subsequent service in the Army Reserves and Colorado Army National Guard from August 1979 to July 2005. This matter comes to the Board of Veterans' Appeal (Board) on appeal from a December 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The Veteran filed a notice of disagreement in January 2007 and was provided with a statement of the case in November 2007. The Veteran perfected his appeal with a January 2008 VA Form 9. The Veteran testified before the undersigned at an April 2011 hearing at the RO (Travel Board hearing). A transcript of that hearing has been associated with the Veteran's claims file. The issues of entitlement to service connection for gout, bilateral hearing loss, tinnitus, and arteriosclerotic heart disease are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's left long finger did not manifest during a period of active service, to include during a period of ACDUTRA or INACDUTRA; or as a result of, active military service. 2. The Veteran's current right hip disability did not manifest during, or as a result of, active military service. 3. The Veteran's left knee disability did not manifest during, or as a result of, active military service. CONCLUSIONS OF LAW 1. The criteria establishing entitlement to service connection for a left long finger disability are not met. 38 U.S.C.A. §§ 101, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.102, 3.303. 2. The criteria establishing entitlement to service connection for a right hip disability are not met. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303. 3. The criteria establishing entitlement to service connection for a left knee disability are not met. 38 U.S.C.A. §§ 1131, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claim submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). These notice requirements were accomplished in letters sent in February 2006 and March 2006. These letters also included notice of the type of evidence necessary to establish a disability rating or effective date for the issues under consideration, pursuant to the holding in Dingess/Hartman v. Nicholson, 19 Vet App 473 (2006). VA also has a duty to assist the Veteran in the development of a claim. This duty includes assisting the Veteran in the procurement of pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). Here, the Veteran's personnel records and post-service VA treatment records have been associated with the claims file. The Board notes that the only service treatment record associated with the Veteran's claims file is a March 1998 periodical examination. Attempts by the RO/AMC and to obtain the Veteran's service treatment records were unsuccessful and in November 2006 the RO made a Formal Finding on the Unavailability of Service Treatment Records from July 1975 to August 1979. Additionally, in December 2012 the RO made a Formal Finding on the Unavailability of Service Treatment Records from August 1979 to July 2005. In such cases, where service treatment records have been lost or destroyed through no fault of the veteran, the Court has held that there is a heightened obligation on the part of VA to explain findings and conclusions and to consider carefully the benefit-of-the-doubt rule. Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board's analysis in this case has been undertaken with the heightened obligation set forth in Cuevas and O'Hare in mind. It is noted, however, that the case law does not lower the legal standard for proving a claim for service connection, but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the claimant. See Russo v. Brown, 9 Vet. App. 46 (1996). The Board also notes that at the April 2011 Board hearing the Veteran identified a "package" that was compiled for promotion in the Army National Guard that was in his possession. The Veteran's Law Judge informed the Veteran that he could submit those materials in support of his claim. Additionally, in a September 2011 letter, the Veteran was informed he could submit additional evidence in support of his claim, including alternative evidence considering his service treatment records are unavailable. To date the Veteran has not submitted the "package" identified at the Board hearing. The Board notes that VA's duty to assist a veteran in developing the facts and evidence pertinent to a veteran's claim is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). As such, a remand to request this evidence is not necessary. The Veteran was also afforded VA examinations in November 2011. In regards to the Veteran's claims for a left long finger disability, right hip disability, and left knee disability, the Board finds that the VA examination reports are adequate because the examiners based their conclusions on clinical evaluations, interview of the Veteran, and review of the Veteran's medical history. See Nieves-Rodriquez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board notes that a March 1998 periodic examination was associated with the claims file after the November 2011 VA examination. However, as will be further discussed below, the Board finds that the March 1998 record is consistent with the November 2011 VA examiner's opinion regarding the Veteran's right hip and left knee disabilities. As such, the Board finds that a remand for an additional opinion addressing the March 1998 record is unnecessary in regards to these issues. As previously noted, the Veteran was provided an opportunity to set forth his contentions during a hearing before the undersigned in August 2011. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that a "hearing officer" who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the undersigned specifically noted the issue on appeal and noted that the evidence the Veteran needed to provide to substantiate his claims. The undersigned also informed the Veteran of alternative records that could substantiate his claim, clarified the Veteran's contentions, and clarified the Veteran's dates of active, Reserve, and National Guard service. As such, the Board finds that the undersigned complied with the aforementioned hearing duties. The Board is also satisfied that there has been substantial compliance with the August 2011 remand directives, which included further attempts to obtain service treatment records, attempts to verify the Veteran's dates of Reserve and National Guard Service, and affording the Veteran VA examinations to determine the nature and etiology of his claimed conditions. Stegall v. West, 11 Vet. App. 268 (1998). Legal Criteria Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Active military, naval, or air service includes any period of ACDUTRA (active duty for training) during which the individual concerned was disabled or died from disease or injury incurred in or aggravated in the line of duty, or any period of INACDUTRA (inactive duty for training) during which the individual concerned was disabled or died from injury (but not disease) incurred in or aggravated in the line of duty. 38 U.S.C.A. §§ 101(21), (24), 106; 38 C.F.R. § 3.6(a), (d). Service connection may also be granted for chronic disabilities if such are shown to have been manifested to a compensable degree within one year after the Veteran was separated from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As an alternative to the nexus requirement, service connection for these chronic disabilities may also be established through a showing of continuity of symptomatology since service. 38 C.F.R. § 3.303(b). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Left Hand Disability The Veteran contends that his left hand injury is related to his military service. First, the Board notes that the Veteran has a current diagnoses of fracture middle finger, proximal mid phalanx, with residual loss of active extension due to extensor tendon injury, as evidenced by the November 2011 VA examination. As stated above, the Veteran's service treatment records are unavailable. However, the Veteran testified at the April 2011 Board hearing that he injured his hand while in the National Guard in 1998 or 1999 when he got his finger stuck under a strap and heard his finger "click". The Veteran further testified that he underwent treatment and surgery on his finger at a civilian hospital. The Board notes that the Veteran is competent to report such an injury. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the Board does not find the Veteran to be credible in his assertions. In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence, and statements made during treatment. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). The Board points to a March 2000 private treatment record that shows the Veteran reported he fell the day prior and sustained a fracture of his left middle finger. The Board also points to a December 2000 private treatment record that shows that the physician, Dr. C., noted that the Veteran sustained a fracture of the left long proximal phalanx in a fall. Specifically, the Veteran reported that he was injured when he fell walking the dog. As such, the Board finds that the Veteran's current statements, made in connection with his pending claims for VA benefits, that he injured his left hand on a strap during reserve service, to be inconsistent with prior contemporaneous statements made for treatment purposes and therefore are not credible. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Consequently, the Board assigns no probative value to the Veteran's assertions that he injured his left hand in service. It is important to point out that the Board does not find that the Veteran's lay statements of an injury during reserve service lack credibility merely because they are unaccompanied by contemporaneous medical evidence, specifically the lack of the Veteran's service treatment records. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (quoting Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). Rather, the current lay statements are found to lack credibility because they are inconsistent and directly contradict the other lay and medical evidence of record, which show the Veteran reported to his treating physician, on more than one occasion, that he injured his long middle finger in a fall, not on a strap during reserve service. The Board also notes that the private treatment records show that the Veteran injured his left long finger on March 8, 2000. A review of the records obtained from the Defense Finance and Accounting Services (DFAS) show that in March 2000, the Veteran had a period of INACDUTRA from March, 17, 2000, to March 19, 2000, with no other service during March 2000. As such, there is no evidence that the Veteran sustained the injury to his left long finger during a period of ACDUTRA or INACDUTRA. Furthermore, even if the Board found the Veteran's report of the injury to his left long finger to be credible, there is no competent medical opinion of record to support the claim. In addition to finding the Veteran's report of the injury to his left long finger to be inconsistent with the private treatment records, the November 2011 VA examiner indicated that even if the Veteran's reported injury to his left long finger was deemed credible, it was unlikely that the Veteran's voluntary withdrawal of his finger from under the pallet's strap would result in so severe an injury. In this regard, the November 2011 VA opinion is considered to be highly persuasive to the issue at hand. The Board notes that the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, his knowledge and skill in analyzing the data, and his medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the November 2011 VA examiner is a Doctor of Osteopathic Medicine and possesses the necessary education, training, and expertise to provide the requested opinion. Additionally, the November 2011 VA opinion is shown to have been based on a review of the Veteran's C-file, and it is accompanied by a sufficient explanation. Furthermore, the November 2011 VA examiner's opinion is consistent with the evidence of record, as private treatment records show the Veteran initially reported injuring his hand in a fall. Additionally, the VA examiner considered and acknowledged the Veteran's lay statements of record in his conclusion. The Board also acknowledges any assertion by the Veteran that his current left long finger is related to his military service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, determining the etiology of decreased range of motion, left hand status post open reduction internal fixation, long finger, left hand, falls outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report the onset of symptoms, any opinion regarding the nature and etiology of his left long finger disability requires medical expertise that the Veteran has not demonstrated. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). As such, the Board assigns no probative weight to the Veteran's assertions that his decreased range of motion, left hand status post open reduction internal fixation, long finger, is in any way related to his military service. Lastly, the Veteran is not entitled to presumptive service connection or service connection based on continuity of symptomatology since his military service as the Veteran's currently diagnosed fracture middle finger, proximal mid phalanx, with residual loss of active extension due to extensor tendon injury, is not considered a chronic disease under the statute. 38 U.S.C.A. § 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307(a), 3.309(a) (2013); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those disorders explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). Given that the Veteran's report of an in-service injury to his left long finger is not credible; and given that there is no competent evidence of a nexus between the Veteran's left long finger disability and service, the weight of the evidence is against a finding of service connection. In reaching this conclusion the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet.App. 49 (1990). Right Hip The Veteran contends that he has a right hip disability that is related to his military service, specifically the wear and tear of running. First, the Veteran is currently diagnosed with a right hip strain as evidenced by the November 2011 VA examination. The Board also notes that the Veteran was diagnosed with trochanteric bursitis by a private physician in January 1999, before the beginning of the appeal period. Again, the Veteran's service treatment records are unavailable. However, the Veteran testified at the April 2011 Board hearing that he was first diagnosed with bursitis in his right hip during active duty service between 1975 and 1979. The Veteran stated the bursitis developed due to his excessive running, which was needed to be done in order to pass his physical fitness tests and be promoted. The Veteran also stated he was diagnosed with right hip bursitis while serving in the Army Reserve in the 1990s, again as a result of his need to pass physical fitness tests. The Board finds that the Veteran's statements are both competent and credible as they are not directly contradicted by the evidence. As such, the Board finds that there is evidence of in-service right hip symptoms. Turning to the question of whether there is a nexus, or link, between the Veteran's current right hip disability and service, the Veteran submitted a buddy statement from S.F dated April 2011. S.F. indicated that from February 1977 to August 1978, he and the Veteran were stationed in Bremerhaven, Germany, and they often worked out and trained together. S.F. stated that during and after exercise periods, he noticed the Veteran suffered from chronic pain in his hips and as a result, the Veteran sought medical help and was diagnosed with bursitis. S.F. further reported that the Veteran was offered a profile to avoid further inflammation and long-term damage; however, the Veteran chose to continue to exercise because the Veteran knew that not taking the physical fitness test would have disqualified him for promotion and further service. As a result, S.F. stated the Veteran's condition did not improve over the period of time they served together. Private treatment records dated January 1999 show that the Veteran was seen for right hip pain over the outside aspect of the right hip on pushing. The Veteran reported that when he starts running he has pain that starts in the back and goes down the front. The Veteran also reported that when he turns to the left while skiing he also has some pain in the area. X-rays of the Veteran's hip were normal, and, as stated above, the Veteran was diagnosed with trochanteric bursitis. The Veteran was prescribed exercises for the hip, including stretching, modalities of heat, cold, and Advil. The physician instructed the Veteran to return in three to four weeks if his symptoms did not improve. There are no additional treatment records for the right hip associated with the claims file. At the November 2011 VA examination the Veteran reported that he began to have pain in the right hip in the early 1990s. The Veteran reported there was no injury to his right hip. The Veteran reported that he was first seen for his hip by a private physician in 1991 or 1992, who diagnosed subtrochanteric bursitis. The Veteran reported that he was told by the private physician to stop running. The Veteran reported that he ran 10 miles per day for years prior to that. The Veteran reported that he had not had another doctor visit for evaluation or treatment of his hip since seeing the private physician. The Veteran reported that his right hip continued to hurt during running and after. The Veteran reported that currently, his right hip hurt constantly and was worse if he walked long distances. The Veteran reported that he stopped running long distances five years prior. The Veteran reported that the location of his pain was the upper anterior iliac crest to the groin. After review of the claims file and physical examination of the Veteran, the November 2011 VA examiner concluded that it was less likely than not that the Veteran's right hip strain is due to any events during service. The examiner stated that there was no evidence of injury during active duty. The examiner also noted that the lay letter reported events different than supported by the record. The examiner noted that the lay letter professed to bilateral hip pain, which the Veteran did not currently have, and which would make it more likely that the lay observation of symptoms was temporary. The examiner also stated that there was no evidence of chronicity of the problems since service since the Veteran had not been treated since seeing a physician one time in 1999. The November 2011 examiner noted that physical examination could not confirm trochanteric bursitis as he did not have tenderness localized over the trochanteric bursa, which is usually seen and the location of his pain was not primarily in the lateral thigh as would be seen with trochanteric bursitis. Again, the Board finds the November 2011 opinion to by highly persuasive to the issue at hand. The November 2011 VA examiner possesses the necessary education, training, and expertise to provide the requested opinion. Additionally, the November 2011 opinion essentially reconciled and substantiated the Veteran's right hip diagnosis, and in doing so, established a sound medical basis for ruling out right hip trochanteric bursa. Furthermore, the November 2011 VA examiner's opinion is consistent with the evidence of record, in that it shows the Veteran was only treated once for right hip pain in 1999. Additionally, the VA examiner considered and acknowledged the lay statements of record in his conclusion. Furthermore, the Board notes that in December 2012 a March 1998 periodic examination is associated with the Veteran's claims file. The report of medical examination shows that the Veteran's lower extremities and spine and other musculoskeletal were normal. Additionally, on his report of medical history the Veteran reported that he suffered from swollen or painful joints. However, in explaining his history of swollen or painful joints, the Veteran only reported issues with his gout and failed to report any symptoms concerning his right hip. Although the March 1998 record was not available to the November 2011 VA examiner, the Board finds that the March 1998 record is consistent with the VA examiner's conclusions. Additionally, the Board finds it reasonable to assume that if the Veteran was suffering from any right hip symptoms at the of the March 1998 examination he would have reported such, as he reported complaints and prior treatment for his gout. The Board acknowledges any assertion by the Veteran that he currently has a diagnosis of right hip trochanteric bursitis or that any hip disability is related to his military service. Again the Board notes that although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. 428, 435, as to the specific issue in this case, the diagnoses of right hip trochanteric bursitis or determining the etiology of a right hip disability, falls outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report the onset of symptoms, any opinion regarding the nature and etiology of his right hip symptoms requires medical expertise that the Veteran has not demonstrated. See Jandreau, 492 F. 3d 1372, 1376. As such, the Board assigns no probative weight to the Veteran's assertions that he currently has right hip trochanteric bursitis or that his right hip disability is in anyway related to his military service. Lastly, the Veteran is not entitled to presumptive service connection or service connection based on continuity of symptomatology since his military service because he does not have a current chronic diagnosis, as stated under the laws and regulations. The Board notes that the Veteran's currently diagnosed right hip strain is not considered a chronic disease under the statute. 38 U.S.C.A. § 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307(a), 3.309(a) (2013); see Walker v. 708 F.3d 1331. Given that there is no competent evidence of a nexus between the Veteran's current right hip disability, and service, the weight of the evidence is against a finding of service connection. In reaching this conclusion, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. Gilbert, 1 Vet.App. 49. Left Knee Condition The Veteran contends that his left knee disability is related to service, specifically the wear and tear of running. First, the Veteran is currently diagnosed with mild degenerative joint disease of the left knee. The Board also notes that a January 1999 private treatment record shows a diagnosis of lateral capsule inflammation versus meniscus tear, left knee. Again, the Veteran's service treatment records are unavailable. However, at the April 2011 Board hearing, the Veteran testified that there was not a specific injury to his left knee but that his condition began during his active duty service in the 1970s and was the result of his constant running. The Veteran further stated his left knee condition symptoms began at the same time as his right hip trochanteric bursitis symptoms. The Veteran testified he stopped running for four and one half years and when he recently tried running again, he said it felt like someone was driving pins in his knees so he quit running. The Board finds that the Veteran's statements are both competent and credible as they are not directly contradicted by the evidence. As such, the Board finds that there is evidence of in-service left knee symptoms. Turning to the question of whether there is a nexus, or link, between the Veteran's current left hip disability and service, the Board again points to the buddy statement from S.F. S.F. also stated that during and after exercise periods from February 1977 to August 1978, he noticed the Veteran was suffering from chronic pain in his knees. The Board also again points to the January 1999 private treatment record. The Veteran reported that he had left knee pain in the posterior lateral aspect of the knee. The Veteran reported that it increased with physical activity, such as running. The Veteran reported that it bothered him to the point where he could not run. The Veteran reported that it did not lock, swell, or give out on him, it was just pain. The Veteran also reported that there was no precipitating injury that he could recall. X-rays of revealed a normal left knee and as stated above, the physician diagnosed lateral capsule inflammation versus meniscus tear, left knee. The Veteran was prescribed anti-inflammatories for the knee and instructed to return in three to four weeks if his symptoms did not improve. The record is absent of any other treatment for the Veteran's left knee. At the November 2011 VA examination the Veteran reported that he first began to have trouble with his left knee in the early 1990s. The Veteran reported that he saw a private physician in the early 1990s who told him his knee pain was due to compensating for his right hip. The examiner noted that the private treatment record does not state this. The Veteran reported that he did not injure his left knee during service or after. The Veteran reported that he does not take medication for his left knee. The Veteran reported that he has not had a magnetic resonance imaging (MRI) of the knee or any surgery. The Veteran reported that he was running 30 to 40 miles per week in the 1980s and 1990s and was running distance until five years prior. The Veteran reported that the pain was located in the lateral joint line. The Veteran also reported that he had not seen a physician for evaluation or treatment of his left knee since the early 1990s. The examiner noted that the private record assessed the Veteran's left knee as "lateral capsule inflammation vs. meniscal tear". The examiner noted that these were widely different diagnosis. X-rays revealed mild degenerative joint disease of the left knee. After review of the claims file and examination of the Veteran the VA examiner concluded that the Veteran's current left knee mild degenerative joint disease was less likely as not related to his right hip. The examiner explained that the right hip condition observed on examination was mild and the Veteran's gait and posture were normal. There was a lack of biomechanical mechanisms such as altered posture or gait due to his right hip to explain injury to the left knee. The examiner noted that there was no evidence that an injury occurred to the Veteran's left knee during service. The examiner also noted that there was no evidence of chronicity presented in that the Veteran has not been seen or treated for his left knee since 1999. The examiner noted the only time the Veteran saw a doctor for his left knee was in 1999 and no diagnosis was given. The examiner also noted that the lay letter stated that both knees and hips were involved and did not report that one was worse than the other. The examiner noted that the Veteran had no problem in the opposite knee currently and this was argument that the knee condition described in the lay letter was a temporary condition and not the current condition. The examiner concluded that the current mild degenerative changes were more likely related to generalized osteoarthritis due to aging. The examiner explained that the Veteran's hand x-ray showed diffused degenerative arthritis, supporting that the Veteran had generalized osteoarthritis. The examiner further explained that the Veteran went on to run long distances for years after 1999 without the need for further medical treatment. The examiner also explained that since the private physician only had a "working diagnosis", and no further evidence such as MRI of the knee to document whether there was a meniscal tear or not, speaks to the fact that a diagnosis for his knee was not really given. The examiner noted that the Veteran did not have physical findings consistent with meniscus injury and an inflammatory condition of the capsule would likely be temporary which was also argued for since the Veteran had not been seen or treated for his left knee since 1999. Again, the Board finds the November 2011 opinion to by highly persuasive to the issue at hand. The November 2011 VA examiner possesses the necessary education, training, and expertise to provide the requested opinion. Additionally, the November 2011 opinion essentially reconciled and substantiated the Veteran's left knee diagnosis, and in doing so, established a sound medical basis for ruling out lateral capsule inflammation versus meniscus tear, left knee and diagnosing mild degenerative joint disease. Furthermore, the November 2011 VA examiner's opinion is consistent with the evidence of record, in that it shows the that the Veteran did not report a specific injury to his left knee and service and that the Veteran was only treated once for left knee pain in 1999. Furthermore, the VA examiner considered and acknowledged the lay statements of record in his conclusion. Finally, while the examiner did not specifically state whether the Veteran's left knee disability was related to service, the Board finds the examiner's rationale sufficiently addresses the question. Again, although the March 1998 record was not available to the November 2011 VA examiner, the Board finds that the March 1998 record is consistent with the VA examiner's conclusions. The March 1998 record shows that while the Veteran reported painful and swollen joints in regards to his gout, he failed to report any symptoms or complaints regarding his left knee. The Board finds it reasonable to assume that if the Veteran was suffering from any left knee symptoms at the time of the March 1998 examination he would have reported such, as he reported complaints and prior treatment for his gout. The Board acknowledges any assertion by the Veteran that his current left knee disability is related to his military service. Again the Board notes that although lay persons are competent to provide opinions on some medical issues, as to the specific issue in this case, determining the etiology of left knee disability, falls outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report the onset of symptoms, any opinion regarding the nature and etiology of his left knee symptoms requires medical expertise that the Veteran has not demonstrated. As such, the Board assigns no probative weight to the Veteran's assertions that his left knee disability is in anyway related to his military service. The Board also acknowledges any assertion by the Veteran that he has had symptoms of left knee pain since his active military service. The Board notes that the Veteran is competent to report on his symptoms. See Washington, 19 Vet. App. 362, 368. However, the Board does not find the Veteran to be credible in his assertions. In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence, and statements made during treatment. See Caluza, 7 Vet. App. 498, 506. The Board finds that the Veteran's assertions that he has suffered from left knee pain since service to be inconsistent with the other (lay and medical) evidence of record. While the buddy statement reported the Veteran had knee pain from February 1977 to August 1978, the Board again points to the March 1998 periodic examination. Again, while the Veteran reported complaints concerning his gout he failed to report any symptoms or complaints regarding his left knee. The Board again finds it reasonable to assume that if the Veteran was suffering from any left knee symptoms he would have reported such, as he reported complaints and prior treatment for his gout. Furthermore, the January 1999 private treatment record shows that the Veteran reported left knee pain. However, the Veteran did not report that he had suffered from this knee pain since service. The Board finds it reasonable to conclude that if the Veteran was suffering from left knee symptoms since service he would have reported such to the private physician, especially as the Veteran provided a detailed explanation of his hip and knee pain and reported previous treatment for his gout. Again, it is important to point out that the Board does not find that the Veteran's lay statements of continuity of his symptoms lack credibility merely because they are unaccompanied by contemporaneous medical evidence, specifically the absence of the Veteran's service treatment records. See Davidson, 581 F.3d 1313 Rather, the current lay statements are found to lack credibility because they are inconsistent with the other lay and medical evidence of record, which show that outside of the Veteran's testimony in conjunction with his application for VA benefits, the Veteran did not report that continuous left knee symptoms since service when seeking treatment and providing a history to treating physcians. See Macarubbo, 10 Vet. App. 388; see also Pond, 12 Vet. App. 341, 345. As such, the Board assigns no probative value to the Veteran's assertion that he has suffered from left knee pain since service. For the reasons set forth above, in regard to continuity of symptoms, the Board finds that the Veteran's left knee disability is properly afforded such consideration, as arthritis is one of the enumerated conditions in 38 C.F.R. § 3.309(a). Walker, 708 F.3d 1331. However, due to the finding that there is no credible or probative evidence of continued left knee symptoms after service, service connection based on continuity of symptomatology is not warranted. Lastly, there is no evidence of record that the Veteran's left knee mild degenerative joint disease manifested to a compensable degree within one year of the Veteran's discharge from service. See 38 C.F.R. § 3.307(a), 3.309(a). Instead, the probative evidence of record shows that the Veteran was not diagnosed with a left knee disability until the November 2011 VA examination, almost four decades after discharge from service and more than six years after discharge from National Guard service. Given that there is no competent evidence of a nexus between the Veteran's current left knee disability and service, the weight of the evidence is against a finding of service connection. In reaching this conclusion the Board has considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the claim, the doctrine is not for application. See, Gilbert, supra. ORDER Entitlement to service connection for a left long finger disability is denied. Entitlement to service connection for a right hip disability is denied. Entitlement to service connection for left knee disability. REMAND Gout The Veteran contends that his gout is related to his military service. As part of the August 2011 Board remand the Veteran was afforded a VA examination in November 2011 to determine the nature and etiology of his gout. The examiner concluded that it was less likely as not that the Veteran's current gout began during active duty. The examiner noted that there was no indication of treatment during active duty. The examiner also noted that the only evidence presented of gout was the January 1999 private treatment record. The examiner also explained that the reported in service symptoms also did not support the onset of gout in service. The examiner explained that the Veteran's in-service events were transient and not recurrent or chronic. The examiner also explained that gout typically begins with symptoms and the great toe which is not the case in the Veteran's history. The Board notes that the November 2011 VA examination appears to be based, at least in part, on an inaccurate factual premise, namely that the Veteran's gout did not start with symptoms in the great toe. The Board notes that the Veteran reported at the November 2011 VA examination that the symptoms began in his great big toe. See Reonal v. Brown, 5 Vet. App. 460, 461 (1993) (an opinion based on an inaccurate factual premise has no probative value). As such, a new VA examination is required. The Board also notes that in November 2012, a March 1998 periodic examination was associated with the Veteran's claims file. On the report of medical history, it was noted that the Veteran had gout of the great toe left foot for the prior three to four years. As this evidence was not part of the claims file at the time of the November 2011 examination and provides evidence that contradicts the November 2011 VA examiner's opinion, the Board finds that it should be considered on remand. Hearing Loss and Tinnitus The Veteran contends that he had bilateral hearing loss and tinnitus that is related to his in-service noise exposure. At the April 2011 Travel Board hearing, the Veteran reported he was a member of a Howitzer battery group. More specifically, the Veteran remarked he was an Artilleryman in 1975 during active duty service and again in 1987 in the Army Reserve. The Veteran testified he began having issues with his hearing during the mid-1980s. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz 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. A January 2006 private treatment record appears to show right ear pure tone thresholds were 25, 20, 30, 35 and 35 decibels at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Left ear pure tone thresholds were 20, 20, 35, 35, and 40 decibels at the same frequencies. The Veteran's speech recognition scores were 100 percent in the right ear and 96 percent in the left ear. The examiner diagnosed mild sensorineural hearing loss bilaterally. The examiner also noted tinnitus, worse in the right ear than in the left. As part of the August 2011 Board remand, the Veteran was afforded a VA examination in November 2011. Right ear pure tone thresholds were 15, 10, 5, 10, and 10 decibels at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Left ear pure tone thresholds were 10, 10, 10, 15, and 10 decibels at the same frequencies. The Veteran's speech recognition scores were 96 percent in the right ear and 98 percent in the left ear. The examiner diagnosed bilateral hearing loss and tinnitus and concluded that the Vetran had normal hearing for VA purposes. The examiner concluded that the Veteran's audiological assessment revealed hearing sensitivity to be well within normal limits bilaterally. The examiner also concluded that the hearing results showed that the Veteran did not have hearing damage while in service. The examiner further concluded that based on the Veteran's current audiological assessment the Veteran did not have hearing damage while in service and his reported tinnitus was less likely as not caused by or a result of noise exposure while in service. The Board notes that during the appeal period the Veteran was shown to have hearing loss for VA purposes, as evidenced by the January 2006 private treatment record. See McLain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the requirement that a claimant have a current disability before service connection may be awarded for that disability is also satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if no disability is present at the time of the claims adjudication). Additionally, the Board notes that the November 2011 VA examiner did not reconcile his audiological findings with the January 2006 private record that showed hearing loss for VA purposes. As such, the Board finds that a new VA examination is necessary to determine whether the Veteran has a current diagnosis of bilateral hearing loss for VA purposes and if so whether it is etiologically related to in-service noise exposure. Again the Board notes that a March 1998 periodic examination was associated with the claims file in November 2012. As the March 1998 record was not available to the November 2011 examiner the Board finds it should be considered on remand. Additionally, as the November 2011 VA examiner's opinion that tinnitus was not related to service was based in part, on normal hearing results at the VA examination; the new VA examination should also address the nature and etiology of the Veteran's tinnitus. Arteriosclerotic heart disease As part of the Board's August 2011 remand, the Veteran was afforded a VA examination to determine the nature and etiology of his heart disability. While the November 2011 VA examinations for the Veteran's other claims are associated with the claims file, the results of the November 2011 VA heart examination are not associated with the Veteran's paper claims file or paperless claims file. There is an indication that a VA heart examination took place, as diagnostic testing results are associated with the claims file and the examination, to include the examiner's opinions, are cited by the AMC in the December 2012 supplemental statement of the case. On remand, this examination report must be associated with the Veteran's VA claims file or Virtual VA file. Bell v. Derwinski, 2 Vet. App. 611 (1992) (holding that documents which were not actually before the adjudicators but had been generated by VA employees or submitted to VA by claimant were, "in contemplation of law, before the Secretary and the Board and should be included in the record"). Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran another opportunity to identify any pertinent treatment records, both VA and private, for his gout, bilateral hearing loss, tinnitus, and heart disability. Specifically, the RO should associate the November 2011 VA examination with the Veteran's claims file. The RO/AMC should secure any necessary authorizations. If any requested outstanding records cannot be obtained, the Veteran should be notified of such. 2. Schedule the Veteran for a new VA examination to determine the nature and etiology of the Veteran's gout. The Veteran's claims folder, including a copy of this REMAND, should be made available to the examiner and reviewed in conjunction with the study in this case. The examination report should include a review and discussion of the Veteran's medical history as well as a comprehensive evaluation, and any tests deemed as necessary. The examiner should then provide an opinion addressing the following questions: Accepting as credible the Veteran's statements and private medical record that he contracted gout during his Army Reserve service, is it at least as likely as not (a 50 percent probability or greater) that the any current diagnosis of gout is related to those symptoms? In the alternative, is it at least as likely as not (a 50 percent probability or greater) that any diagnosis of gout had its onset during Army Reserve service, or was otherwise caused by his military service in any way? The examiner should specifically discuss the March 1998 periodic examination. The Board also advises that the Veteran reported at the November 2011 VA examination that his symptoms began in his left great big toe. The reasons and bases for all opinions expressed should be provided and the report should include a discussion of the Veteran's documented medical history, statements and assertions. 3. Schedule the Veteran for a new VA examination to determine the nature and etiology of the Veteran's hearing loss and tinnitus. The entire claims file, to include a complete copy of this REMAND, must be made available to the examiner and the report of examination should include discussion of the Veteran's documented medical history and assertions. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. If any hearing loss disability and/or tinnitus is diagnosed, also with respect to each ear, the physician should offer an opinion, consistent with sound medical principles, as to whether it is at least as likely as not (50 percent or greater probability) that such disability/disabilities is/are the result of an injury or disease (to particularly include alleged in-service noise exposure) incurred or aggravated by a disease or injury during any period of service. The examiner should specifically address the private January 2006 and November 2011 VA audiometric findings and reconcile any differing diagnoses. The reasons and bases for all opinions expressed should be provided and the report should include a discussion of the Veteran's documented medical history, statements and assertions. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his or her representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs